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October 1, 2017An Update for Highmark Health Options Providers and CliniciansMedical and Drug Policies Update Notice for Nov. 1, Effect DateNEW MEDICAID DRUG POLICIESAvastin . . . . . . . . . . . . 2Erbitux . . . . . . . . . . . . 3Fasoldex. . . . . . . . . . . 4Kyprolis . . . . . . . . . . . . 5Ocrevus . . . . . . . . . . . . 6Perjeta . . . . . . . . . . . . . 7Rituxan. . . . . . . . . . . . . 8Xolair. . . . . . . . . . . . . . . 9Tysabri . . . . . . . . . . . . . 10NEW MEDICAID MEDICAL POLICIESCardiac Rehabilitation, Phase II Outpatient . . . . 11Colorectal Cancer Screening . . . . . . . . . . . . . 12Macular Degeneration . . . . . . . . . . . . . . . . . . . . 13Molecular Markers for Lung Cancer . . . . . . . . . 14Pulmonary Rehabilitation . . . . . . . . . . . . . . . . . . .15REVISED MEDICAID MEDICAL POLICIESContinuos Glucose Monitoring. . . . . . . . . . . . . . . . . . . . . 16Fetal Aneuploidy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Genetic Testing for Colorectal Cancer Susceptibility . . . . 18Highmark Health Options Place of Service. . . . . . . . . . . 19REVISED MEDICAID DRUG POLICIESIVIG New Covered Diagnosis Code . . . . . . . 20Portrazza – New J Code Created . . . . . . . . . 21Spinraza – added new HCPS Code . . . . . . . 22Highmark Health Options is an independent licensee of the Blue Cross and Blue Shield Associationwww.highmarkhealthoptions.com
2Avastin (bevacizumab)CLINICAL MEDICAL POLICYPolicy Name:Avastin (bevacizumab)Policy Number:MP-030-MD-DEResponsible Department(s):Medical Management; Clinical PharmacyProvider Notice Date:10/01/2017Original Effective Date:11/01/2017Annual Approval Date:09/12/2018Revision Date:N/AProducts:Highmark Health Options MedicaidApplication:All participating hospitals and providersPage Number(s):1POLICY SUMMARYHighmark Health Options provides coverage under the medical surgical benefits of theCompany’s Medicaid products for cervical cancer, colorectal cancer, glioblastoma, nonsquamous non-small cell lung cancer, ovarian cancer, and renal cancer when medicallynecessary.*The full version of this medical policy is available on the Highmark Health Optionsprovider website icalAndPaymentPolicyDISCLAIMERHighmark Health Options medical policy is intended to serve only as a general reference resourceregarding payment and coverage for the services described. This policy does not constitute medical adviceand is not intended to govern or otherwise influence medical decisions.Highmark Health Options is an independent licensee of the Blue Cross and Blue Shield Association
3Erbitux (cetuximab)CLINICAL MEDICAL POLICYPolicy Name:Erbitux (cetuximab)Policy Number:MP-034-MD-DEResponsible Department(s):Medical Management; Clinical PharmacyProvider Notice Date:10/01/2017Original Effective Date:11/01/2017Annual Approval Date:09/12/2018Revision Date:N/AProducts:Highmark Health Options MedicaidApplication:Page Number(s):All participating hospitals and providers1POLICY SUMMARYHighmark Health Options provides coverage under the medical benefits of the Company’sMedicaid products for medically necessary intravenous infusions of Erbitux (cetuximab).*The full version of this medical policy is available on the Highmark Health Optionsprovider website icalAndPaymentPolicyDISCLAIMERHighmark Health Options medical policy is intended to serve only as a general reference resourceregarding payment and coverage for the services described. This policy does not constitute medical adviceand is not intended to govern or otherwise influence medical decisions.Highmark Health Options is an independent licensee of the Blue Cross and Blue Shield Association
4Faslodex (fulvestrant)CLINICAL MEDICAL POLICYPolicy Name:Faslodex (fulvestrant)Policy Number:MP-044-MD-DEResponsible Department(s):Medical Management; Clinical PharmacyProvider Notice Date:10/01/2017Original Effective Date:11/01/2017Annual Approval Date:09/12/2018Revision Date:N/AProducts:Highmark Health Options MedicaidApplication:Page Number(s):All participating hospitals and providers1POLICY SUMMARYHighmark Health Options provides coverage under the medical benefits of theCompany’s Medicaid products for medically necessary intravenous infusion ofFaslodex (fulvestrant).*The full version of this medical policy is available on the Highmark Health Optionsprovider website icalAndPaymentPolicyDISCLAIMERHighmark Health Options medical policy is intended to serve only as a general reference resourceregarding payment and coverage for the services described. This policy does not constitute medical adviceand is not intended to govern or otherwise influence medical decisions.Highmark Health Options is an independent licensee of the Blue Cross and Blue Shield Association
5Kyprolis (carfilzomib)CLINICAL MEDICAL POLICYPolicy Name:Kyprolis (carfilzomib)Policy Number:MP-043-MD-DEResponsible Department(s):Medical Management; Clinical PharmacyProvider Notice Date:10/01/2017Original Effective Date:11/01/2017Annual Approval Date:09/12/2018Revision Date:N/AProducts:Highmark Health Options MedicaidApplication:All participating hospitals and providersPage Number(s):1POLICY SUMMARYHighmark Health Options provides coverage under the medical surgical and specialtypharmacy benefits of the Company’s Medicaid products for medically necessaryintravenous infusions of Kyprolis (carfilzomib).*The full version of this medical policy is available on the Highmark Health Optionsprovider website icalAndPaymentPolicyDISCLAIMERHighmark Health Options medical policy is intended to serve only as a general reference resourceregarding payment and coverage for the services described. This policy does not constitute medical adviceand is not intended to govern or otherwise influence medical decisions.Highmark Health Options is an independent licensee of the Blue Cross and Blue Shield Association
6Ocrevus (Ocrelizumab)CLINICAL MEDICAL POLICYPolicy Name:Policy Number:MP-056-MD-DEResponsible Department(s):Medical Management; Clinical PharmacyProvider Notice Date:10/01/2017Original Effective Date:11/01/2017Annual Approval Date:09/12/2018Revision Date:N/AProducts:Highmark Health Options MedicaidApplication:All participating hospitals and providersPage Number(s):1Ocrevus (Ocrelizumab)POLICY SUMMARYHighmark Health Options provides coverage under the medical benefits of theCompany’s Medicaid products for medically necessary Ocrevus (ocrelizumab)intravenous administration for the treatment of relapsing-remitting or primaryprogressive multiple sclerosis (MS).*The full version of this medical policy is available on the Highmark Health Optionsprovider website icalAndPaymentPolicyDISCLAIMERHighmark Health Options medical policy is intended to serve only as a general reference resourceregarding payment and coverage for the services described. This policy does not constitute medical adviceand is not intended to govern or otherwise influence medical decisions.
7Perjeta (pertuzumab)CLINICAL MEDICAL POLICYPolicy Name:Perjeta (pertuzumab)Policy Number:MP-045-MD-DEResponsible Department(s):Medical Management; Clinical PharmacyProvider Notice Date:10/01/2017Original Effective Date:11/01/2017Annual Approval Date:09/12/2018Revision Date:N/AProducts:Highmark Health Options MedicaidApplication:All participating hospitals and providersPage Number(s):1POLICY SUMMARYHighmark Health Options provides coverage under the medical surgical and specialtypharmacy benefits of the Company’s Medicaid and Medicare products for medicallynecessary intravenous infusions of Perjeta (pertuzumab).*The full version of this medical policy is available on the Highmark Health Optionsprovider website icalAndPaymentPolicyDISCLAIMERHighmark Health Options medical policy is intended to serve only as a general reference resourceregarding payment and coverage for the services described. This policy does not constitute medical adviceand is not intended to govern or otherwise influence medical decisions.
8Rituxan (rituximab)CLINICAL MEDICAL POLICYPolicy Name:Rituxan (rituximab)Policy Number:MP-031-MD-DEResponsible Department(s):Medical Management; Clinical PharmacyProvider Notice Date:10/01/2017Original Effective Date:11/01/2017Annual Approval Date:09/12/2018Revision Date:N/AProducts:Highmark Health Options MedicaidApplication:Page Number(s):All participating hospitals and providers1POLICY SUMMARYHighmark Health Options provides coverage under the medical benefits of theCompany’s Medicaid products for medically necessary intravenous infusions ofRituxan (rituximab).*The full version of this medical policy is available on the Highmark Health Optionsprovider website icalAndPaymentPolicyDISCLAIMERHighmark Health Options medical policy is intended to serve only as a general reference resourceregarding payment and coverage for the services described. This policy does not constitute medical adviceand is not intended to govern or otherwise influence medical decisions.
9Xolair (omalizumab)CLINICAL MEDICAL POLICYPolicy Name:Xolair (omalizumab)Policy Number:Responsible Department(s):MP-051-MD-DEMedical Management; Clinical PharmacyProvider Notice Date:10/01/2017Original Effective Date:11/01/2017Annual Approval Date:09/12/2018Revision Date:N/AProducts:Highmark Health Options MedicaidApplication:Page Number(s):All participating hospitals and providers1POLICY SUMMARYHighmark Health Options provides coverage under the medical surgical benefits of theCompany’s Medicaid products for medically necessary Xolair (omalizumab) subcutaneousinjections.*The full version of this medical policy is available on the Highmark Health Optionsprovider website icalAndPaymentPolicyDISCLAIMERHighmark Health Options medical policy is intended to serve only as a general reference resourceregarding payment and coverage for the services described. This policy does not constitute medical adviceand is not intended to govern or otherwise influence medical decisions.
10Tysabri (natalizumab)CLINICAL MEDICAL POLICYPolicy Name:Policy Number:Tysabri (natalizumab)MP-042-MD-DEResponsible Department(s):Medical Management; Clinical PharmacyProvider Notice Date:10/01/2017Original Effective Date:11/01/2017Annual Approval Date:09/12/2018Revision Date:N/AProducts:Highmark Health Options MedicaidApplication:All participating hospitals and providersPage Number(s):1POLICY SUMMARYHighmark Health Options provides coverage for intravenous immunoglobulin (IVIG)and subcutaneous immune globulin (SCIG) under the medical benefits of theCompany’s Medicaid products for medically necessary Tysabri (natalizumab)intravenous administration.*The full version of this medical policy is available on the Highmark Health Optionsprovider website icalAndPaymentPolicyDISCLAIMERHighmark Health Options medical policy is intended to serve only as a general reference resourceregarding payment and coverage for the services described. This policy does not constitute medical adviceand is not intended to govern or otherwise influence medical decisions.
11Cardiac Rehabilitation, Phase II OutpatientCLINICAL MEDICAL POLICYPolicy Name:Policy Number:MP-057-MD-DEResponsible Department(s):Medical ManagementProvider Notice Date:10/01/2017Original Effective Date:11/01/2017Annual Approval Date:09/01/2018Revision Date:08/09/2017Products:Highmark Health Options MedicaidApplication:All participating hospitals and providersPage Number(s):1Cardiac Rehabilitation, Phase II OutpatientPOLICY SUMMARYHighmark Health Options provides coverage under the medical benefits of theCompany’s Medicaid products for medically necessary outpatient and medicallysupervised Phase II cardiac rehabilitation programs. Phase III and phase IV cardiacrehabilitation programs are considered maintenance programs and not medicallynecessary.*The full version of this medical policy is available on the Highmark Health Optionsprovider website icalAndPaymentPolicyDISCLAIMERHighmark Health Options medical policy is intended to serve only as a general reference resourceregarding payment and coverage for the services described. This policy does not constitute medical adviceand is not intended to govern or otherwise influence medical decisions.
12Colorectal Cancer ScreeningCLINICAL MEDICAL POLICYPolicy Name:Colorectal Cancer ScreeningPolicy Number:MP-059-MD-DEResponsible Department(s):Medical ManagementProvider Notice Date:10/01/2017Original Effective Date:11/01/2017Annual Approval Date:09/12/2018Revision Date:N/AProducts:Highmark Health Options MedicaidApplication:All participating hospitals and providersPage Number(s):1POLICY SUMMARYHighmark Health Options provides coverage under the medical surgical benefits ofthe Company’s Medicaid products for medically necessary colorectal cancer screeningprocedures.*The full version of this medical policy is available on the Highmark Health Optionsprovider website icalAndPaymentPolicyDISCLAIMERHighmark Health Options medical policy is intended to serve only as a general reference resourceregarding payment and coverage for the services described. This policy does not constitute medical adviceand is not intended to govern or otherwise influence medical decisions.
13Age-Related Macular Degeneration TreatmentsCLINICAL MEDICAL POLICYPolicy Name:Policy Number:Age-Related Macular Degeneration TreatmentsMP-060-MD-DEResponsible Department(s):Medical ManagementProvider Notice Date:10/01/2017Original Effective Date:11/01/2017Annual Approval Date:09/01/2018Revision Date:N/AProducts:Highmark Health Options MedicaidApplication:All participating hospitals and providersPage Number(s):1POLICY SUMMARYHighmark Health Options provides coverage under the medical surgical benefits ofthe Company’s Medicaid products of wet age-related macular degeneration andadvanced, end-stage age-related macular degeneration.* The full version of this medical policy is available on the Highmark Health Optionsprovider website icalAndPaymentPolicyDISCLAIMERHighmark Health Options medical policy is intended to serve only as a general reference resourceregarding payment and coverage for the services described. This policy does not constitute medical adviceand is not intended to govern or otherwise influence medical decisions.
14Molecular Tumor Markers for Non-Small CellLung Cancer (NSCLC)CLINICAL MEDICAL POLICYPolicy Name:Molecular Tumor Markers for Non-Small Cell Lung Cancer(NSCLC)Policy Number:MP-061-MD-DEResponsible Department(s):Medical ManagementProvider Notice Date:10/01/2017Original Effective Date:11/01/2017Annual Approval Date:09/01/2018Revision Date:N/AProducts:Highmark Health Options MedicaidApplication:Page Number(s):All participating hospitals and providers1POLICY SUMMARYHighmark Health Options provides coverage under the medical surgical benefits ofthe Company’s Medicaid products for medically necessary molecular tumor markersfor non-small cell lung cancer.*The full version of this medical policy is available on the Highmark Health Optionsprovider website icalAndPaymentPolicyDISCLAIMERHighmark Health Options medical policy is intended to serve only as a general reference resourceregarding payment and coverage for the services described. This policy does not constitute medical adviceand is not intended to govern or otherwise influence medical decisions.
15Pulmonary Rehabilitation (PR)CLINICAL MEDICAL POLICYPolicy Name:Policy Number:Pulmonary Rehabilitation (PR)MP-058-MD-DEResponsible Department(s):Medical ManagementProvider Notice Date:10/01/2017Original Effective Date:11/01/2017Annual Approval Date:09/06/2018Revision Date:N/AProducts:Highmark Health Options MedicaidApplication:All participating hospitals and providersPage Number(s):1POLICY SUMMARYHighmark Health Options does not provide coverage under the medical surgicalbenefits of the Company’s Medicaid products for medically necessary pulmonaryrehabilitation.*The full version of this medical policy is available on the Highmark Health Optionsprovider website icalAndPaymentPolicyDISCLAIMERHighmark Health Options medical policy is intended to serve only as a general reference resourceregarding payment and coverage for the services described. This policy does not constitute medical adviceand is not intended to govern or otherwise influence medical decisions.
16Long‐Term Use Continuous Glucose Monitoring ofInterstitial FluidCLINICAL MEDICAL POLICYPolicy Name:Long‐Term Use Continuous Glucose Monitoring ofInterstitial FluidPolicy Number:MP-040-MD-DEResponsible Department(s):Medical ManagementProvider Notice Date:10/01/2017Original Effective Date:11/01/2017Annual Approval Date:09/01/2018Revision Date:N/AProducts:Highmark Health Options MedicaidApplication:Page Number(s):All participating hospitals and providers1POLICY SUMMARYHighmark Health Options provides coverage under the durable medical equipment(DME) benefits of the Company’s Medicaid products for medically necessary longterm use of continuous glucose monitors. This policy has been updated to include theprocedure code for an artificial pancreas device system (S1034).*The full version of this medical policy is available on the Highmark Health Optionsprovider website icalAndPaymentPolicyDISCLAIMERHighmark Health Options medical policy is intended to serve only as a general reference resourceregarding payment and coverage for the services described. This policy does not constitute medical adviceand is not intended to govern or otherwise influence medical decisions.
17Fetal Aneuploidy Testing Using Noninvasive CellFree Fetal DNACLINICAL MEDICAL POLICYPolicy Name:Fetal Aneuploidy Testing Using Noninvasive Cell-Free FetalDNAPolicy Number:MP-003-MD-DEResponsible Department(s):Medical ManagementProvider Notice Date:10/01/2017Original Effective Date:11/01/2017Annual Approval Date:09/01/2018Revision Date:03/15/2017Products:Highmark Health Options MedicaidApplication:All participating hospitals and providersPage Number(s):1POLICY SUMMARYHighmark Health Options provides coverage for laboratory benefit under the medical benefitsof the Company’s Medicaid products for medically necessary, noninvasive, circulating cell-freeDNA prenatal testing of fetal aneuploidy as screening tools for trisomy 21 (Down syndrome),trisomy 18 (Edwards syndrome) or trisomy 13 (Patau syndrome). Circulating cell-free fetal DNAcrosses the placenta and can be isolated in maternal plasma. The medical necessity criteria,Summary of Literature and Reference sections of this policy has been updated.*The full version of this medical policy is available on the Highmark Health Options providerwebsite icalAndPaymentPolicyDISCLAIMERHighmark Health Options medical policy is intended to serve only as a general reference resource regardingpayment and coverage for the services described. This policy does not constitute medical advice and is notintended to govern or otherwise influence medical decisions.
18Genetic Testing for Colorectal Cancer SusceptibilityCLINICAL MEDICAL POLICYPolicy Name:Policy Number:Responsible Department(s):Genetic Testing for Colorectal Cancer SusceptibilityMP-018-MD-DEMedical ManagementProvider Notice Date:10/01/2017Original Effective Date:11/01/2017Annual Approval Date:09/01/2018Revision Date:08/09/2017, 03/14/2017Products:Hig
Oct 01, 2017 · Kyprolis (carfilzomib) POLICY SUMMARY. Highmark Health Options provides coverage under the medical surgical and specialty pharmacy benefits of the Company’s Medicaid products for medically necessary intravenous infusions of Kyprolis (carfilzomib). *The full version of this m
