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Prior Authorization Updates for Elitek®, Abraxane® & Paclitaxel Protein- Bound Particles, Neulasta® and Udenyca® Effective March 1, 2023

Audience: Participating Hematologists and Oncologists

We would like to provide advance notice regarding prior authorization requirements for the following drugs when billed under the member’s medical benefit. These updates are effective March 1, 2023, and apply to all lines of business.

To ensure accurate prescribing and correct claim submissions, please follow the requirements outlined below and share this important information with your billing office/billing service and anyone within your practice who should be aware.

Elitek (rasburicase)

As of March 1, 2023, Elitek will require prior authorization to ensure appropriate use. Elitek is FDA approved for the initial management of plasma uric acid levels in pediatric and adult patients with leukemia, lymphoma, and solid tumor malignancies who are receiving anticancer therapy expected to result in tumor lysis and subsequent elevation of plasma uric acid.

This change impacts new starts only and does not apply to existing users. If submitting a prior authorization request for Elitek, please include all of the following relevant clinical information: 

  • Diagnosis
  • Clinical justification as to why Elitek is the best choice for your patient

Elitek (rasburicase) is provider-administered; billed to member’s medical benefit

J-code

NDC

J2783 Injection, rasburicase, 0.5 mg

ELITEK 1.5MG Solution Reconstituted

00024-5150-10

ELITEK 7.5MG Solution Reconstituted

00024-5151-75

Abraxane® and paclitaxel protein-bound particles

As of March 1, 2023, Abraxane and paclitaxel protein-bound particles will require prior authorization and will only be approved for the following diagnoses:

  • Ampullary adenocarcinoma
  • Biliary tract cancer
  • Pancreatic adenocarcinoma

The use of Abraxane or paclitaxel protein-bound particles for all other diagnoses will require a documentation of a medical reason why conventional paclitaxel (Taxol®) cannot be used. Conventional paclitaxel (Taxol) does not require prior authorization.

These changes impact new starts only and do not apply to existing users. If submitting a prior authorization request for Abraxane or paclitaxel protein-bound particles, please include all of the following relevant clinical information:

  • Diagnosis
  • If the diagnosis is not ampullary adenocarcinoma, biliary tract cancer, or pancreatic adenocarcinoma, please provide clinical justification as to why conventional paclitaxel (Taxol) is not the best choice for your patient

Conventional Paclitaxel (Taxol) is provider-administered; billed to member’s medical benefit

J-code

NDC

J9267 Injection, paclitaxel, 1 mg

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Paclitaxel 6mg/ml Solution

  • 68001-0516-27
  • 70860-0215-66
  • 70860-0215-67
  • 61703-0342-09
  • 61703-0342-22
  • 61703-0342-50
  • 16714-0137-01
  • 72205-0061-01
  • 72205-0062-01
  • 72205-0063-01
  • 00703-3216-01
  • 00703-3218-81
  • 67457-0471-52
  • 47781-0595-07
  • 70860-0200-05
  • 70860-0200-17
  • 70860-0200-50
  • 63323-0763-05
  • 63323-0763-16
  • 63323-0763-50

Paclitaxel 300mg/50ml Concentrate

  • 70860-0215-68
  • 00703-3218-01

Paclitaxel 30mg/ 5ml Concentrate

  • 0703-3213-81
  • 15054-1120-04

Paclitaxel 6mg/ ml Concentrate

  • 00703-3213-01

Paclitaxel 100mg/ 16.7ml Concentrate

  • 00703-3216-81

Paclitaxel 150mg/ 25ml Concentrate

  • 00703-3217-01

Neulasta® and Udenyca® (pegfilgrastim)

As of March 1, 2023, Neulasta and Udenyca will require prior authorization to ensure appropriate use.  Neulasta and Udenyca will continue to remain the preferred pegfilgrastim agents.

Prescribing Requirements

Neulasta

Prior Authorization Required (starting 3/1/23)

Preferred Drug

Udenyca

Prior Authorization Required (starting 3/1/23)

Preferred Drug

Fulphila®

Prior Authorization Required

Non-Preferred Drug

Nyvepria™

Prior Authorization Required

Non-Preferred Drug

Ziextenzo®

Prior Authorization Required

Non-Preferred Drug

Fylnetra®

Prior Authorization Required

Non-Preferred Drug

Rolvedon™

Prior Authorization Required

Non-Preferred Drug

When submitting a prior authorization request for the above drugs, please include all of the following relevant and required clinical information:

  • Diagnosis
  • If requesting a non-preferred drug, please provide clinical justification as to why Neulasta or Udenyca are not the best choice for your patient

This change impacts new starts only and does not apply to existing users.

Neulasta and Udenyca (pegfilgrastim)

Medical Benefit Billing Requirements (preferred drugs)

J-code/Q-code

NDC

J2506 Injection, pegfilgrastim, excludes biosimilar, 0.5 mg

Neulasta Onpro 6mg/0.6ml Solution:

  • 55513-0192-01

Neulasta 6mg/0.6ml Solution:

  • 5513-0190-01

Q5111 Injection, Pegfilgrastim-cbqv, biosimilar, (udenyca), 0.5 mg

Udenyca 6mg/0.6ml Solution Prefilled Syringe:

  • 70114-0101-01

These formulary and policy changes were reviewed and approved by our Pharmacy & Therapeutics (P&T) Committee, which is comprised of local physicians and pharmacists who are not employed by our Health Plan.

If you have questions or concerns, please contact your Provider Relations representative.

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