| Effective Date:01/01/2013 |
Title:Zaltrap
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| Revision Date:01/01/2017
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Document:BI396:00
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| CPT Code(s):J9400
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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)
Zaltrap is
an intravenous drug used to treat metastatic colorectal cancer.
2)
Zaltrap is
covered under the medical benefit as a specialty drug.
3)
Zaltrap (Ziv-Aflibercept)
requires prior authorization.
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Medical Statement
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Zaltrap is considered
medically necessary for patients who meet ALL of the following criteria:
1)
Diagnosis
of metastatic colorectal cancer AND
2)
Resistant
to or progressed following an oxaliplatin-containing regimen AND
3)
Is used in
combination with 5-fluorouracil, leucovorin and irinotecan (FOLFIRI).
Codes
Used In This BI:
J9400 Ziv-Aflibercept Injection, 1mg
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Limits
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Intentially left empty
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Reference
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1)
Zaltrap
Product Information. Sanofi Aventis. Bridgewater, NJ; August 2012
2)
National
Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Colon
Cancer / Rectal Cancer v.1.2013
3)
Zaltrap.
Clinical Pharmacology. Accessed online January 2013.
Addendum:
Effective
01/01/2017: Removed HCPCS Code C9296 from Claim Statement & Codes Used
In This BI section. This code is no longer valid effective 1/1/14.
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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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