| Effective Date:01/01/2016 |
Title:Farydak (Panobinostat)
|
| Revision Date:
|
Document:BI489:00
|
| 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)
Farydak (panobinostat)
requires prior authorization.
2)
Farydak is
used to treat relapsed multiple myeloma.
3)
Farydak is
covered under the pharmacy benefit as a specialty drug.
|
|
Medical Statement
|
|
Farydak (Panobinostat)
is considered medically necessary when the following criteria are met:
1)
Diagnosis of
relapsed multiple myeloma (C90.02) AND
2)
Patient has
received at least two prior therapies, including Bortezomib and an
Immunomodulatory agent AND
3)
Will be used
with Bortezomib and Dexamethasone
|
|
Limits
|
|
Intentially left empty
|
|
Reference
|
|
1)
Farydak
Prescribing Information. Novartis Pharmaceuticals Corp. East Hanover, NJ.
February 2015.
2)
Clinical
Pharmacology. Accessed online 9/11/2015.
3)
NCCN Drugs &
Biologics Compendium. Panobinostat. Accessed online 9/11/2015.
|
|
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.
|