healthcare operations utilization protocols 2007 - Health Plan of ...

HEALTHCARE OPERATIONS
UTILIZATION PROTOCOLS 2007
• Bullous pemphigoid (BP)
• Mucous membrane pemphigoid (MMP)(a.k.a., cicatricial pemphigoid)
• Epidermolysis bullosa acquista (EBA)
‣ ACTION: Will approve for 6 months
3. ** NOTE: May be approved in patients with rapidly progressive disease in whom a clinical
response could not be affected quickly enough using conventional agents. In such situations,
IVIg therapy should be given along with conventional treatment(s) and the IVIg would be
used only until conventional therapy could take effect.
4. Patient has a diagnosis of CIDP (Chronic Idiopathic Demyelinating
5. Approval for other, off-label indications will be considered on a case-by-case basis with
clinical information submitted.
6. For Approval for other, off-label indications will be considered on a case-by-case basis with
clinical information submitted.
7. Per Medicare coverage guidance, may be approved for other indications in Medicare
members if it is supported in the recognized compendia.
8. If the above criteria are not met, the request will be denied.
Coverage Information – IVIG
Senior Dimensions MA-PD plans – covered under the Medicare Part B benefit only if
medication is being used for one of the diagnoses listed in #1 above; applicable 20% coinsurance
will apply and will NOT apply to TrOOP. Covered under Medicare Part D
benefit for all other diagnoses with the applicable specialty drug co-insurance and WILL
apply to TrOOP. All claims will adjudicate through the pharmacy on-line claims system.
Sierra RX – covered under the Medicare Part B benefit only if medication is being used for
one of the diagnoses listed in #1 above; direct member to their Part B carrier. Covered
under Medicare Part D benefit for all other diagnoses with the applicable specialty drug coinsurance;
will adjudicate through the pharmacy online claims system and WILL apply to
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This guideline is to be used in the decision-making process and does not represent standards of care of an individual
patient. The use of this guideline should not substitute for the professional judgment of a provider which takes into
account the unique problems and circumstances of the individual patient. They are proprietary documents and may
not be copied or distributed without express permission.