HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
I-31-023
Topic:
Tocilizumab (Actemra)
Section:
Injections
Effective Date:
August 1, 2024
Issued Date:
August 1, 2024
Last Revision Date:
March 2024
Annual Review:
November 2023
 
 

Tocilizumab (Actemra®), tocilizumab-bavi (TofidenceTM) and and tocilizumab-aazg (Tyenne®) are recombinant humanized anti-human interleukin 6 (IL-6) receptor monoclonal antibodies that work to inhibit IL-6 mediated actions at soluble and membrane bound IL-6 receptors. Inhibiting the signaling pathway can lead to inhibition of activated T- and B-cells, lymphocytes, monocytes, and fibroblasts.

Policy Position

Tocilizumab (Actemra) for Intravenous (IV) Use

Tocilizumab (Actemra) IV injection may be considered medically necessary when an individual meets the criteria for ANY ONE of the following:

  • Cytokine Release Syndrome (CRS):
    • The individual is two (2) years of age and older with severe or life threatening CRS induced by chimeric antigen receptor T-cell (CAR-T) therapy; or
  • Giant Cell Arteritis (GCA):
    • The inidivual is 18 years of age and older for the treatment of GCA; and
    • Treatment with at least one (1) systemic corticosteriod (e.g. prednisone) was ineffective and not tolerated, or all crticosteriods are contraindicated; or
  • Management of Immunotherapy-Related Toxicities:
    • For management of CAR-T related toxicities such as:
      • G2-4 CRS; or
      • G1-4 neurotoxicity as additional single-dose therapy if concurrent CRS; or
    • For management of prolonged (greater than 3 days) G1 CRS in individuals with significant symptoms and/or comorbidities; or
    • For management of immune checkpoint inhibitor-related toxicities as additional management of severe immunotherapy-related inflammatory arthritis if symptoms do not improve within 2 weeks of starting high-dose corticosteroids; or
  • Juvenile Idiopathic Arthritis, Polyarticular (PJIA):
    • The individual is two (2) years of age and older with active PJIA; and
    • Treatment with at least one (1) disease modifying anti-rheumatic drug (DMARD) (e.g. methotrexate, leflunomide, sulfasalazine) was ineffective or not tolerated, or all non-biologic DMARDs are contraindicated; or
    • The individual requires initial biologic therapy due to involvement of high-risk joints (e.g., cervical spine, wrist, or hip), high disease activity, and/or those judged by their provider to be at high risk of disabling joint damage; or
  • Juvenile Idiopathic Arthritis, Systemic (SJIA):
    • For individuals two (2) years of age and older with active SJIA; and
    • Treatment with at least one (1) non-biologic DMARD (e.g. methotrexate, leflunomide, sulfasalazine) was ineffective or not tolerated, or all non-biologic DMARDs are contraindicated; or
  • Rheumatoid Arthritis (RA):
    • The individual is 18 years of age and older with moderately to severely active RA; and
    • Treatment with at least one (1) non-biologic DMARD (e.g. methotrexate, leflunomide, sulfasalazine) was ineffective or not tolerated, or all non-biologic DMARDs are contraindicated; and

Compendia Sources

  • Tocilizumab (Actemra) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.

Reauthorization Criteria (for non-oncologic indications)

Continuation of therapy with tocilizumab (Actemra) for may be considered medically necessary when the following criteria are met:

  • The individual has one of the above diagnoses; and
  • Provider attestation that individual has demonstrated a disease stability or beneficial response to therapy; and
  • Reauthorization valid for 12 months.

The use of tocilizumab (Actemra IV) not meeting the criteria as indicated in this policy is considered not medically necessary.

J3262

 

 

 

 

 

 

 




Tocilizumab (Actemra) for Subcutaneous (SC) Use

Tocilizumab (Actemra) SC injection may be considered medically necessary when an individual meets the criteria for ANY ONE of the following indications:

  • Giant Cell Arteritis (GCA):
    • The individual is 18 years of age and older for the treatment of GCA; and
    • Treatment with at least one (1) systemic corticosteroid (e.g., prednisone) was ineffective or not tolerated, or all corticosteroids are contraindicated; or
  • Juvenile Idiopathic Arthritis, Polyarticular (PJIA):
    • The individual is two (2) years of age and older with PJIA; and
    • ONE of the following criteria is met:
      • Treatment with at least one (1) non-biologic DMARD was ineffective or not tolerated, or all non-biologic DMARDs are contraindicated; or
      • The individual requires initial biologic therapy due to involvement of high-risk joints (e.g., cervical spine, wrist, or hip), high disease activity, and/or those judged by their physician to be at high risk of disabling joint damage; and
  • Systemic Juvenile Idiopathic Arthritis (SJIA):
    • The individual is two (2) years of age and older with active SJIA; or
  • Rheumatoid Arthritis (RA):
    • The individual is 18 years of age and older with moderately to severely active RA; and
    • Treatment with at least one (1) non-biologic DMARD was ineffective or not tolerated, or all non-biologic DMARDs are contraindicated; or
  • Systemic Sclerosis-Associated Interstitial Lung Disease (SSc-ILD)
    • The individual is 18 years of age or older with SSc-ILD; and
    • Tocilizumab (Actemra) is being prescribed by or in consultation with a pulmonologist or rheumatologist; and
    • The individual has documentation of a high-resolution chest computed tomography (HRCT) scan demonstrating greater than or equal to 10% pulmonary fibrosis; and
    • The individual has a baseline forced vital capacity (FVC) of at least 40% and a percent predicted diffusing capacity of the lungs of carbon monoxide (DLCO) of at least 30%; and
    • The individual is a non-smoker or is currently engaged in smoking cessation.

Reauthorization Criteria

Continuation of therapy with tocilizumab (Actemra) for may be considered medically necessary when the following criteria are met:

  • The individual has one of the above diagnoses; and
  • Provider attestation that individual has demonstrated a disease stability or beneficial response to therapy; and
  • Reauthorization valid for 12 months.

The use of tocilizumab (Actemra SC) not meeting the criteria as indicated in this policy is considered not medically necessary.

J3262

 

 

 

 

 

 




Tocilizumab-bavi (Tofidence)

Tocilizumab-bavi (Tofidence) may be considered medically necessary when an individual meets the criteria for ANY ONE of the following:

  • Juvenile Idiopathic Arthritis, Polyarticular (PJIA):
    • The individual is two (2) years of age and older with PJIA; and
    • ONE of the following criteria is met:
      • Treatment with at least one (1) non-biologic DMARD was ineffective or not tolerated, or all non-biologic DMARDs are contraindicated; or
      • The individual requires initial biologic therapy due to involvement or high-risk joints (e.g., cervical spine, wrist, or hip), high disease activity, and/or those judges by their physician to be at high risk of disabling joint damage; or
  • Systemic Juvenile Ipiopathic Arthritus (Sjia):
    • The individual is two (2) years of age and older with active SJIA; and
    • Treatment with at least one (1) non-biologic DMARD (e.g. methotrexate, leflunomide, sulfasalazine) was ineffective or not tolerated, or all non-biologic DMARDs are contraindicated; or
  • Rheumatoid Arthritis (RA):
    • The individual is 18 years of age and older with moderately to severaly active RA; and
    • Treatment with at least one (1) non-biologic DMARD was ineffective or not tolerate, or all non-biologic DMARDs are contraindicated.

Reauthorization Criteria

Continuation of therapy with tocilizumab-bavi (Tofidence) for may be considered medically necessary when the following criteria are met:

  • The individual has one of the above diagnoses; and
  • Provider attestation that individual has demonstrated a disease stability or beneficial response therapy; and
  • Reauthorization valid for 12 months.

The use of tocilizumab-bavi (tofidence) not meeting the criteria as indicated in this policy is considered not medically necessary. 

Q5133

 

 

 

 

 

 




Tocilizumab-aazg (Tyenne)

Tocilizumab-aazg (Tyenne) may be considered medically necessary when an individual meets the criteria for ANY ONE of the following:

  • Giant Cell Arthritis (GCA) 
    • The individual is 18 years of age and older for the treatment of GCA; and
    • Treatment with at least one (1) systemic corticosteroid (e.g., prednisone) was ineffective or not tolerated, or all corticosteroids are contraindicated; or
  • Juvenile Idiopathic Arthritis, Polyarticular (PJIA):
    • The individual is two (2) years of age and older with PJIA; and
    • ONE of the following criteria is met:
      • Treatment with at least one (1) non-biologic DMARD was ineffective or not tolerated, or all non-biologic DMARDs are contraindicated; or
      • The individual requires initial biologic therapy due to involvement of high-risk joints (e.g., cervical spine, wrist, or hip), high disease activity, and/or those judged by their physician to be at high risk of disabling joint damage; or
  • Systemic Juvenile Idiopathic Arthritis (SJIA):
    • The individual is two (2) years of age and older with active SJIA; and
    • Treatment with at least one (1) non-biologic DMARD (e.g. methotrexate, leflunomide, sulfasalazine) was ineffective or not tolerated, or all non-biologic DMARDs are contraindicated; or
  • Rheumatoid Arthritis (RA):
    • The individual is 18 years of age and older with moderately to severely active RA; and
    • Treatment with at least one (1) non-biologic DMARD was ineffective or not tolerated, or all non-biologic DMARDs are contraindicated.

Reauthorization Criteria

Continuation of therapy with tocilizumab-aazg (Tyenne) for may be considered medically necessary when the following criteria are met:

  • The individual has one of the above diagnoses; and
  • Provider attestation that individual has demonstrated a disease stability or beneficial response to therapy; and
  • Reauthorization valid for 12 months.

The use of tocilizumab-aazg (Tyenne) not meeting the criteria as indicated in this policy is considered not medically necessary.

J3490

 

 

 

 

 

 




Tocilizumab (Actemra) and tocilizumab-bavi (Tofidence) may be considered medically necessary for individuals 18 years of age and older when applicable clinical criteria for individual medication policies are met and when administered in a physician’s office not affiliated with a hospital, specialized infusion centers not affiliated with a hospital or in the home. 

Outpatient facility (Outpatient Hospital IV Infusion Department or Hospital-based Outpatient Clinical Level of Care) administration may be considered medically necessary if ANY of the following criteria are present to indicate the member is medically unstable for infusions in other than an outpatient facility setting:

  • Member’s home is considered unsuitable for care by the home infusion provider; or
  • Individual’s medical status requires enhanced monitoring beyond that which would routinely be needed for infusion therapy; or
  • Previous severe adverse reaction (including but not limited to anaphylaxis, seizure, thromboembolism, myocardial infarction, renal failure) during or following administration of prescribed medication despite standard pre-medication; or
  • Individual is receiving other medications that require close monitoring with a higher level of care (e.g., cytotoxic chemotherapy or blood products); or
  • Individual is at high risk for complications due to medication administration (e.g., at risk for post-transplant complications, increased risk of infusion reactions due to presence of circulating antibodies, unstable vascular access, cardiopulmonary condition at risk for severe adverse reactions, unstable renal function with inability to safely tolerate IV volume loads, etc.); or 
  • Individual is initiating therapy or re-initiating therapy after a period of at least 6 months with no therapy; or
  • Physically and/or cognitively impaired AND a home caregiver is not available to comply with the required treatment regimen and schedule.

Home health services may be considered medically necessary when utilized for the administration of home infusion therapy and when provided by licensed eligible provider. Each case will be addressed on an individual basis.

 

The medications identified in this policy will be considered not medically necessary if administered in an unapproved hospital outpatient setting when an approved site of care is a viable option for treatment.

J3262

Q5133

 

 

 

 

 




NOTE: If an individual has already had a trial of at least one biologic agent, they are not required to “step back” and try a non-biologic agent.

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Highmark may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.


Related Policies

See pharmacy policy J-558 Chronic Inflammatory Diseases for additional information.

Refer to medical policy I-151 Site of Care for more information.


Covered Diagnosis Codes for Procedure Code J3262

D89.831

D89.832

D89.833

D89.834

D89.835

D89.839

G92.01

G92.02

G92.03

G92.04

G92.05

M05.00

M05.011

M05.012

M05.019

M05.021

M05.022

M05.029

M05.031

M05.032

M05.039

M05.041

M05.042

M05.049

M05.051

M05.052

M05.059

M05.061

M05.062

M05.069

M05.071

M05.072

M05.079

M05.09

M05.111

M05.112

M05.121

M05.122

M05.131

M05.132

M05.141

M05.142

M05.151

M05.152

M05.161

M05.162

M05.171

M05.172

M05.19

M05.20

M05.211

M05.212

M05.219

M05.221

M05.222

M05.229

M05.231

M05.232

M05.239

M05.241

M05.242

M05.249

M05.251

M05.252

M05.259

M05.261

M05.262

M05.269

M05.271

M05.272

M05.279

M05.29

M05.30

M05.311

M05.312

M05.319

M05.321

M05.322

M05.329

M05.331

M05.332

M05.339

M05.341

M05.342

M05.349

M05.351

M05.352

M05.359

M05.361

M05.362

M05.369

M05.371

M05.372

M05.379

M05.39

M05.40

M05.411

M05.412

M05.419

M05.421

M05.422

M05.429

M05.431

M05.432

M05.439

M05.441

M05.442

M05.449

M05.451

M05.452

M05.459

M05.461

M05.462

M05.469

M05.471

M05.472

M05.479

M05.49

M05.50

M05.511

M05.512

M05.519

M05.521

M05.522

M05.529

M05.531

M05.532

M05.539

M05.541

M05.542

M05.549

M05.551

M05.552

M05.559

M05.561

M05.562

M05.569

M05.571

M05.572

M05.579

M05.59

M05.60

M05.611

M05.612

M05.619

M05.621

M05.622

M05.629

M05.631

M05.632

M05.639

M05.641

M05.642

M05.649

M05.651

M05.652

M05.659

M05.661

M05.662

M05.669

M05.671

M05.672

M05.679

M05.69

M05.7A

M05.70

M05.711

M05.712

M05.719

M05.721

M05.722

M05.729

M05.731

M05.732

M05.739

M05.741

M05.742

M05.749

M05.751

M05.752

M05.759

M05.761

M05.762

M05.769

M05.771

M05.772

M05.779

M05.79

M05.8A

M05.80

M05.811

M05.812

M05.819

M05.821

M05.822

M05.829

M05.831

M05.832

M05.839

M05.841

M05.842

M05.849

M05.851

M05.852

M05.859

M05.861

M05.862

M05.869

M05.871

M05.872

M05.879

M05.89

M05.9

M06.0A

M06.00

M06.011

M06.012

M06.019

M06.021

M06.022

M06.029

M06.031

M06.032

M06.039

M06.041

M06.042

M06.049

M06.051

M06.052

M06.059

M06.061

M06.062

M06.069

M06.071

M06.072

M06.079

M06.08

M06.09

M06.1

M06.20

M06.211

M06.212

M06.219

M06.221

M06.222

M06.229

M06.231

M06.232

M06.239

M06.241

M06.242

M06.249

M06.251

M06.252

M06.259

M06.261

M06.262

M06.269

M06.271

M06.272

M06.279

M06.28

M06.29

M06.30

M06.311

M06.312

M06.319

M06.321

M06.322

M06.329

M06.331

M06.332

M06.339

M06.341

M06.342

M06.349

M06.351

M06.352

M06.359

M06.361

M06.362

M06.369

M06.371

M06.372

M06.379

M06.38

M06.39

M06.4

M06.8A

M06.80

M06.811

M06.812

M06.819

M06.821

M06.822

M06.829

M06.831

M06.832

M06.839

M06.841

M06.842

M06.849

M06.851

M06.852

M06.859

M06.861

M06.862

M06.869

M06.871

M06.872

M06.879

M06.88

M06.89

M06.9

M08.0A

M08.00

M08.011

M08.012

M08.019

M08.021

M08.022

M08.029

M08.031

M08.032

M08.039

M08.041

M08.042

M08.049

M08.051

M08.052

M08.059

M08.061

M08.062

M08.069

M08.071

M08.072

M08.079

M08.08

M08.09

M08.2A

M08.20

M08.211

M08.212

M08.219

M08.221

M08.222

M08.229

M08.231

M08.232

M08.239

M08.241

M08.242

M08.249

M08.251

M08.252

M08.259

M08.261

M08.262

M08.269

M08.271

M08.272

M08.279

M08.28

M08.29

M08.3

M08.4A

M08.40

M08.411

M08.412

M08.419

M08.421

M08.422

M08.429

M08.431

M08.432

M08.439

M08.441

M08.442

M08.449

M08.451

M08.452

M08.459

M08.461

M08.462

M08.469

M08.471

M08.472

M08.479

M08.48

M08.80

M08.811

M08.812

M08.819

M08.821

M08.822

M08.829

M08.831

M08.832

M08.839

M08.841

M08.842

M08.849

M08.851

M08.852

M08.859

M08.861

M08.862

M08.869

M08.871

M08.872

M08.879

M08.88

M08.89

M08.9A

M08.90

M08.911

M08.912

M08.919

M08.921

M08.922

M08.929

M08.931

M08.932

M08.939

M08.941

M08.942

M08.949

M08.951

M08.952

M08.959

M08.961

M08.962

M08.969

M08.971

M08.972

M08.979

M08.98

M08.99

M31.5

M31.6

M34.81

R65.10

R65.11

T45.1X5A

T45.1X5D

T45.1X5S

T80.90XA

T80.90XD

T80.90XS

 

 

 

 

 

 

 

Covered Diagnosis Codes for Procedure Code Q5133

M05.7A

M05.8A

M05.9

M05.00

M05.09

M05.19

M05.20

M05.29

M05.30

M05.39

M05.40

M05.49

M05.50

M05.59

M05.60

M05.69

M05.70

M05.79

M05.80

M05.89

M05.011

M05.012

M05.019

M05.021

M05.022

M05.029

M05.031

M05.032

M05.039

M05.041

M05.042

M05.049

M05.051

M05.052

M05.059

M05.061

M05.062

M05.069

M05.071

M05.072

M05.079

M05.111

M05.112

M05.121

M05.122

M05.131

M05.132

M05.141

M05.142

M05.151

M05.152

M05.161

M05.162

M05.171

M05.172

M05.211

M05.212

M05.219

M05.221

M05.222

M05.229

M05.231

M05.232

M05.239

M05.241

M05.242

M05.249

M05.251

M05.252

M05.259

M05.261

M05.262

M05.269

M05.271

M05.272

M05.279

M05.311

M05.312

M05.319

M05.321

M05.322

M05.329

M05.331

M05.332

M05.339

M05.341

M05.342

M05.349

M05.351

M05.352

M05.359

M05.361

M05.362

M05.369

M05.371

M05.372

M05.379

M05.411

M05.412

M05.419

M05.421

M05.422

M05.429

M05.431

M05.432

M05.439

M05.441

M05.442

M05.449

M05.451

M05.452

M05.459

M05.461

M05.462

M05.469

M05.471

M05.472

M05.479

M05.511

M05.512

M05.519

M05.521

M05.522

M05.529

M05.531

M05.532

M05.539

M05.541

M05.542

M05.549

M05.551

M05.552

M05.559

M05.561

M05.562

M05.569

M05.571

M05.572

M05.579

M05.611

M05.612

M05.619

M05.621

M05.622

M05.629

M05.631

M05.632

M05.639

M05.641

M05.642

M05.649

M05.651

M05.652

M05.659

M05.661

M05.662

M05.669

M05.671

M05.672

M05.679

M05.711

M05.712

M05.719

M05.721

M05.722

M05.729

M05.731

M05.732

M05.739

M05.741

M05.742

M05.749

M05.751

M05.752

M05.759

M05.761

M05.762

M05.769

M05.771

M05.772

M05.779

M05.811

M05.812

M05.819

M05.821

M05.822

M05.829

M05.831

M05.832

M05.839

M05.841

M05.842

M05.849

M05.851

M05.852

M05.859

M05.861

M05.862

M05.869

M05.871

M05.872

M05.879

M06.0A

M06.1

M06.4

M06.8A

M06.9

M06.00

M06.08

M06.09

M06.20

M06.28

M06.29

M06.30

M06.38

M06.39

M06.80

M06.88

M06.89

M06.011

M06.012

M06.019

M06.021

M06.022

M06.029

M06.031

M06.032

M06.039

M06.041

M06.042

M06.049

M06.051

M06.052

M06.059

M06.061

M06.062

M06.069

M06.071

M06.072

M06.079

M06.211

M06.212

M06.219

M06.221

M06.222

M06.229

M06.231

M06.232

M06.239

M06.241

M06.242

M06.249

M06.251

M06.252

M06.259

M06.261

M06.262

M06.269

M06.271

M06.272

M06.279

M06.311

M06.312

M06.319

M06.321

M06.322

M06.329

M06.331

M06.332

M06.339

M06.341

M06.342

M06.349

M06.351

M06.352

M06.359

M06.361

M06.362

M06.369

M06.371

M06.372

M06.379

M06.811

M06.812

M06.819

M06.821

M06.822

M06.829

M06.831

M06.832

M06.839

M06.841

M06.842

M06.849

M06.851

M06.852

M06.859

M06.861

M06.862

M06.869

M06.871

M06.872

M06.879

M08.0A

M08.2A

M08.3

M08.4A

M08.9A

M08.00

M08.08

M08.09

M08.20

M08.28

M08.29

M08.40

M08.48

M08.80

M08.88

M08.89

M08.90

M08.98

M08.99

M08.011

M08.012

M08.019

M08.021

M08.022

M08.029

M08.031

M08.032

M08.039

M08.041

M08.042

M08.049

M08.051

M08.052

M08.059

M08.061

M08.062

M08.069

M08.071

M08.072

M08.079

M08.211

M08.212

M08.219

M08.221

M08.222

M08.229

M08.231

M08.232

M08.239

M08.241

M08.242

M08.249

M08.251

M08.252

M08.259

M08.261

M08.262

M08.269

M08.271

M08.272

M08.279

M08.411

M08.412

M08.419

M08.421

M08.422

M08.429

M08.431

M08.432

M08.439

M08.441

M08.442

M08.449

M08.451

M08.452

M08.459

M08.461

M08.462

M08.469

M08.471

M08.472

M08.479

M08.811

M08.812

M08.819

M08.821

M08.822

M08.829

M08.831

M08.832

M08.839

M08.841

M08.842

M08.849

M08.851

M08.852

M08.859

M08.861

M08.862

M08.869

M08.871

M08.872

M08.879

M08.911

M08.912

M08.919

M08.921

M08.922

M08.929

M08.931

M08.932

M08.939

M08.941

M08.942

M08.949

M08.951

M08.952

M08.959

M08.961

M08.962

M08.969

M08.971

M08.972

M08.979

 

Covered Diagnosis Codes for Procedure Code J3490

M05.7A

M05.8A

M05.9

M05.00

M05.09

M05.19

M05.20

M05.29

M05.30

M05.39

M05.40

M05.49

M05.50

M05.59

M05.60

M05.69

M05.70

M05.79

M05.80

M05.89

M05.011

M05.012

M05.019

M05.021

M05.022

M05.029

M05.031

M05.032

M05.039

M05.041

M05.042

M05.049

M05.051

M05.052

M05.059

M05.061

M05.062

M05.069

M05.071

M05.072

M05.079

M05.111

M05.112

M05.121

M05.122

M05.131

M05.132

M05.141

M05.142

M05.151

M05.152

M05.161

M05.162

M05.171

M05.172

M05.211

M05.212

M05.219

M05.221

M05.222

M05.229

M05.231

M05.232

M05.239

M05.241

M05.242

M05.249

M05.251

M05.252

M05.259

M05.261

M05.262

M05.269

M05.271

M05.272

M05.279

M05.311

M05.312

M05.319

M05.321

M05.322

M05.329

M05.331

M05.332

M05.339

M05.341

M05.342

M05.349

M05.351

M05.352

M05.359

M05.361

M05.362

M05.369

M05.371

M05.372

M05.379

M05.411

M05.412

M05.419

M05.421

M05.422

M05.429

M05.431

M05.432

M05.439

M05.441

M05.442

M05.449

M05.451

M05.452

M05.459

M05.461

M05.462

M05.469

M05.471

M05.472

M05.479

M05.511

M05.512

M05.519

M05.521

M05.522

M05.529

M05.531

M05.532

M05.539

M05.541

M05.542

M05.549

M05.551

M05.552

M05.559

M05.561

M05.562

M05.569

M05.571

M05.572

M05.579

M05.611

M05.612

M05.619

M05.621

M05.622

M05.629

M05.631

M05.632

M05.639

M05.641

M05.642

M05.649

M05.651

M05.652

M05.659

M05.661

M05.662

M05.669

M05.671

M05.672

M05.679

M05.711

M05.712

M05.719

M05.721

M05.722

M05.729

M05.731

M05.732

M05.739

M05.741

M05.742

M05.749

M05.751

M05.752

M05.759

M05.761

M05.762

M05.769

M05.771

M05.772

M05.779

M05.811

M05.812

M05.819

M05.821

M05.822

M05.829

M05.831

M05.832

M05.839

M05.841

M05.842

M05.849

M05.851

M05.852

M05.859

M05.861

M05.862

M05.869

M05.871

M05.872

M05.879

M06.0A

M06.1

M06.4

M06.8A

M06.9

M06.00

M06.08

M06.09

M06.20

M06.28

M06.29

M06.30

M06.38

M06.39

M06.80

M06.88

M06.89

M06.011

M06.012

M06.019

M06.021

M06.022

M06.029

M06.031

M06.032

M06.039

M06.041

M06.042

M06.049

M06.051

M06.052

M06.059

M06.061

M06.062

M06.069

M06.071

M06.072

M06.079

M06.211

M06.212

M06.219

M06.221

M06.222

M06.229

M06.231

M06.232

M06.239

M06.241

M06.242

M06.249

M06.251

M06.252

M06.259

M06.261

M06.262

M06.269

M06.271

M06.272

M06.279

M06.311

M06.312

M06.319

M06.321

M06.322

M06.329

M06.331

M06.332

M06.339

M06.341

M06.342

M06.349

M06.351

M06.352

M06.359

M06.361

M06.362

M06.369

M06.371

M06.372

M06.379

M06.811

M06.812

M06.819

M06.821

M06.822

M06.829

M06.831

M06.832

M06.839

M06.841

M06.842

M06.849

M06.851

M06.852

M06.859

M06.861

M06.862

M06.869

M06.871

M06.872

M06.879

M08.0A

M08.2A

M08.3

M08.4A

M08.9A

M08.00

M08.08

M08.09

M08.20

M08.28

M08.29

M08.40

M08.48

M08.80

M08.88

M08.89

M08.90

M08.98

M08.99

M08.011

M08.012

M08.019

M08.021

M08.022

M08.029

M08.031

M08.032

M08.039

M08.041

M08.042

M08.049

M08.051

M08.052

M08.059

M08.061

M08.062

M08.069

M08.071

M08.072

M08.079

M08.211

M08.212

M08.219

M08.221

M08.222

M08.229

M08.231

M08.232

M08.239

M08.241

M08.242

M08.249

M08.251

M08.252

M08.259

M08.261

M08.262

M08.269

M08.271

M08.272

M08.279

M08.411

M08.412

M08.419

M08.421

M08.422

M08.429

M08.431

M08.432

M08.439

M08.441

M08.442

M08.449

M08.451

M08.452

M08.459

M08.461

M08.462

M08.469

M08.471

M08.472

M08.479

M08.811

M08.812

M08.819

M08.821

M08.822

M08.829

M08.831

M08.832

M08.839

M08.841

M08.842

M08.849

M08.851

M08.852

M08.859

M08.861

M08.862

M08.869

M08.871

M08.872

M08.879

M08.911

M08.912

M08.919

M08.921

M08.922

M08.929

M08.931

M08.932

M08.939

M08.941

M08.942

M08.949

M08.951

M08.952

M08.959

M08.961

M08.962

M08.969

M08.971

M08.972

M08.979

M31.5

M31.6

 

 

 

 

 



Place of Service: Outpatient- Infusion

Evidence-based guidelines support the administration of injectable medications in alternative sites of care such as the non-hospital physician’s office, non-hospital infusion center or in the home.  Administration of the injectable medications subject to this policy at alternate sites of care is based upon the professional judgment of the provider, and takes into account the clinical appropriateness for each individual member. Requests for administration of any dose of the drugs listed in this policy received from a hospital-based facility, physician’s office or specialized infusion center will be assessed for meeting the policy exception criteria based on the clinical documentation provided by the requesting practitioner.



The policy position applies to all commercial lines of business



Links






This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.





Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.