Xgeva≥nericName=denosumab∨gName=Anthem Blue Cross - 2014 to Present (HMO, PPO, EPO) ()
Hormones⊂class=Drugs for Menopause and Bone Loss : 
  • APPROVAL CRITERIA: May be approved when criteria are met for any of the following indications: I. Diagnosis of Crohn's Disease (CD) when the following criteria are met: a. Individual is 18 years of age or older; AND b. Individual has a diagnosis of moderately to severely active CD; AND c. Individual has failed to respond to, is intolerant of, or has a medical contraindication to conventional therapies (such as 5-ASA products, systemic corticosteroids, or immunosuppressants) and Cimzia (certolizumab pegol) is used for one of the following: 1. To reduce signs or symptoms; OR 2. To induce or maintain clinical response; AND d. Individual has had an inadequate response to TWO preferred biologic therapies in the previous 180 days. (Current preferred biologics include - Humira (adalimumab) and Remicade (infliximab)) II. Diagnosis of Rheumatoid Arthritis (RA) when the following criteria are met: a. Individual is 18 years of age or older; AND b. Individual has a diagnosis of moderately to severely active RA; AND c. Agent is used for any of the following reasons: 1. To reduce signs or symptoms; OR 2. To induce or maintain clinical response; OR 3. To improve physical function; AND d. Individual has failed to respond to, is intolerant of, or has a medical contraindication to one or more nonbiologic DMARDs (disease-modifying antirheumatic drugs); AND e. Individual has had an inadequate response to TWO preferred biologic therapies in the previous 180 days. (Current preferred biologics include - Enbrel (etanercept), Humira (adalimumab), Remicade (infliximab), or golimumab (Simponi or Simponi Aria)) III. Ankylosing Spondylitis (AS) when the following are met: a. Individual is 18 years of age or older with active AS; AND b. Agent is being used to reduce signs or symptoms of the disease; AND c. Individual has failed to respond to, is intolerant of, or has medical contraindication to conventional therapy (such as NSAIDs or nonbiologic DMARDs); AND d. Individual has had an inadequate response to TWO preferred biologic therapies in the previous 180 days. (Current preferred biologics include - Remicade (infliximab), Enbrel (etanercept), Humira (adalimumab), or Simponi (golimumab)) IV. Psoriatic Arthritis (PsA) when the following are met: a. Individual is 18 years of age or older with active PsA; AND b. Agent is being used for any of the following reasons: 1. To reduce signs or symptoms; OR 2. To induce or maintain clinical response; OR 3. To improve physical function; AND c. Individual has failed to respond to, is intolerant of, or has a medical contraindication to conventional therapy (such as nonbiologic DMARDs); AND d. Individual has had an inadequate response to TWO preferred biologic therapies in the previous 180 days. (Current preferred biologics include - Remicade (infliximab), Enbrel (etanercept), Humira (adalimumab), or Simponi (golimumab)) V. May NOT be approved for individuals with any of the following: a. Tuberculosis, invasive fungal infection, other active serious infections, or a history of recurrent infections; or b. Individuals who have not had a tuberculin skin (TST), or a CDC-recommended equivalent, to evaluate for latent tuberculosis; or c. Using in combination with other TNF antagonists; or d. Using in combination with tofacitinib citrate; or e. Using in combination with the following non-TNF immunomodulatory drugs: abatacept (Orencia), anakinra (Kineret), natalizumab (Tysabri), or rituximab (Rituxan). APPROVAL DURATION: 1 year.
  • Zero Copay;
  • PA_APPLIES
  • Hemophilia (Factor XIII Deficiency):
    Duration: 1 year(s)
    Documented Diagnosis: No
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Dosing Limit(s): N/A
    Treatment Center Required: No