| Effective Date:01/01/2018 |
Title:Vyxeos (Daunorubicin / Cytarabine(
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| Revision Date:
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Document:BI569:00
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| CPT Code(s):
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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)
Vyxeos
(Daunorubicin/Cytarabine) requires prior authorization.
2)
Vyxeos is used to treat a
type of leukemia.
3)
Vyxeos is covered under
the medical benefit as a specialty drug.
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Medical Statement
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Vyxeos (daunorubicin/cytarabine) is considered medically necessary for adults
age 18 and older to treat newly diagnosed therapy-related acute myelogenous
leukemia (AML) or AML with myelodysplasia-related changes.
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Limits
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Intentially left empty
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Reference
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1)
Vyxeos Prescribing
Information. Jazz Pharmaceuticals. August 2017.
2)
Clinical Pharmacology.
Accessed online November 14, 2017.
3)
NCCN Drugs and Biologics
Compendium. Accessed online November 14, 2017.
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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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