| Effective Date:04/01/2012 |
Title:Halaven (Eribulin)
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| Revision Date:01/01/2017
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Document:BI346:00
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| CPT Code(s):J9179
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Public Statement
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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)
Halaven (Eribulin)
requires prior authorization.
2)
Halaven is
considered a specialty medication.
3)
Halaven is
used to treat patients with metastatic breast cancer and soft tissue sarcomas.
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Medical Statement
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Halaven is considered medically necessary for members who meet the following
criteria:
1)
Diagnosis
of metastatic breast cancer (C50.011-C50.929)
AND
2)
Have
previously received at least two (2) chemotherapeutic regimens for the treatment
of metastatic disease including an anthracycline (doxorubicin or epirubicin) and
a taxanes (docetaxel or paclitaxel). OR
3)
Diagnosis
of soft tissue sarcoma, including angiosarcoma, retroperitoneal/intra-abdominal,
rhabdomyosarcoma and sarcoma of the extremity/superficial trunk, head/neck.
Codes
Used In This BI:
J9179 Eribulin mesylate injection
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Limits
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Intentially left empty
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Reference
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1)
Halaven
Product Information. EISAI. November 2010.
2)
Clinical
Pharmacology Online. “Eribulin”, retrieved December 2011.
3)
NCCN Drugs
and Biologic Compendium. Accessed online November 22, 2016.
Addendum:
Effective 01/01/2017: Updated approved diagnoses of soft tissue
sarcomas.
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Application to Products
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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.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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