Hereditary Angioedema - BMC HealthNet Plan

More documents

Recommendations

Info

Firazyr ®Kalbitor ®3. Documentation that the member requires treatment for acuteHAE attacks; AND4. The member must be at least 18 years of age; AND5. The member must have a history of acute facial, laryngeal, orgastrointestinal angioedema attacks due to HAE3. Documentation that the member requires treatment for acuteHAE attacks; AND4. The member must be at least16 years of age; AND5. The member must have a history of acute facial, laryngeal, orgastrointestinal angioedema attacks due to HAE; AND6. Documentation of the plan for medication administration by ahealthcare professional in a facility equipped to provideappropriate medical support to manage anaphylaxis andhereditary angioedema; AND7. Documentation that the member has received the medicationguide required as part of the FDA Risk Management Strategy(REMS) program for Kalbitor ®Cinryze TM3. Documentation that the member requires prophylactictreatment for HAE; AND4. The member must be at least 12 years of age; AND5. The member has failed or could not tolerate a trial of anattenuated androgen or has a documented medicalcontraindication to androgen therapy** (e.g. danazol,oxandrolone, methyltestosterone); AND6. The member must meet at least one of the following criteriafor long-term HAE prophylaxis:a. More than one severe event per monthb. More than 24 days per year affected by HAEc. History of a recurrent laryngeal attacksContinuation of Therapy (Duration of Approval – Maximum of 3 months)The prescriber must provide all of the following documentation for continuation ofBerinert ® , Cinryze TM , Firazyr ® and Kalbitor ® therapy:Cinryze TM1. Significant improvement in severity and duration of attackshave been achieved and sustained; ANDThis guideline provides information on BMC HealthNet Plan clinical criteria and claims adjudication processing guidelines. Theuse of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement isbased on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Planpolicies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider.Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the mostrecent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accreditingorganization guidelines and requirements, including NCQA.This document is subject to further revision in response to additional terms and requirements imposed under the Integrated CareProgram, including the ICP contract.BMCHP refers to Boston Medical Center HealthNet Plan in Massachusetts and Well Sense Health Plan in New Hampshire.Boston Medical Center HealthNet Plan and Well Sense Health Plan are trade names used by Boston Medical Center Health Plan,Inc.4 of 7BMC HealthNet Plan – Hereditary Angioedema
Berinert ® ,Firazyr ® , andKalbitor ®2. Clinical documentation of functional improvement have beenachieved and sustained.1. Significant improvement in severity and duration of attackshave been achieved and sustained; AND2. The member is receiving prophylactic therapy with attenuatedandrogens or C1 INH if the member has filled Berinert ® ,Firazyr ® or Kalbitor ® more than once per month for 3 of thelast 6 months (as evidenced by pharmacy claims)3. Documentation of member adherence to prophylactic therapyfor HAE if applicable.*BMC HealthNet Plan will NOT approve coverage of Berinert ® , Cinryze TM , andKalbitor ® for the treatment or prevention of angioedema due to causes other thanHAE.**Adherence to prescribed androgen therapy must be confirmed by prescriptionclaims. If the member is new to BMC HealthNet Plan and does not have a prescriptionclaims history, the prescriber must certify that the member has been adherent to theprescribed androgen therapy.Quantity Limitations Apply – see Appendix AApplicable Coding:J-CodeMedicationJ0597 C1 esterase inhibitor (human), 10 units (Berinert ® )J0598 C1 esterase inhibitor (human) 10 units (Cinryze TM )J1290 Ecallantide 1mg (Kalbitor ® )--- Icantibant (Firazyr ® )Limitations:BMC HealthNet Plan will not approve coverage of Berinert ® , Cinryze TM , Firazyr ® andKalbitor ® in the following instances:1. When the above criteria are not met.This guideline provides information on BMC HealthNet Plan clinical criteria and claims adjudication processing guidelines. Theuse of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement isbased on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Planpolicies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider.Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the mostrecent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accreditingorganization guidelines and requirements, including NCQA.This document is subject to further revision in response to additional terms and requirements imposed under the Integrated CareProgram, including the ICP contract.BMCHP refers to Boston Medical Center HealthNet Plan in Massachusetts and Well Sense Health Plan in New Hampshire.Boston Medical Center HealthNet Plan and Well Sense Health Plan are trade names used by Boston Medical Center Health Plan,Inc.5 of 7BMC HealthNet Plan – Hereditary Angioedema
Page 1 and 2: BMCHP.ORG1-888-566-0008WELLSENSE.OR
Page 3: Attenuated androgens have been show
Page 7: Last Review Date: 03/14/2013 - P&T

Hereditary Angioedema - BMC HealthNet Plan

Create successful ePaper yourself

Delete template?

Save as template?