Medical Policy

Effective Date:01/01/2012 Title:Erivedge (Vismodegib)
Revision Date:10/01/2014 Document:BI358:00
CPT Code(s):None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Erivedge (Vismodegib) requires prior authorization.

2)    Erivedge is used to treat basal cell carcinoma, a type of skin cancer, in adults.

3)    Erivedge is covered under the pharmacy benefit as a specialty drug.

Medical Statement

Erivedge (Vismodegib) is considered medically necessary for adult patients who meet the following criteria:

1)    Patient is 18 years of age or older  AND

2)    Diagnosis of metastatic or locally advanced basal cell carcinoma.   AND

3)    Disease has recurred following surgery or patient is not a candidate for surgery or radiation. 

Limits

As a specialty drug, Erivedge is limited to the contracted specialty pharmacy.

 

Reference

 

1)    Erivedge Product Information.  Genentech.  2012

2)    Clinical Pharmacology.  Erivedge.  Accessed online March 2012.

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.