Prior authorization for denosumab products (Xgeva and biosimilars)
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This document governs prior authorization requests for denosumab products (Xgeva and listed biosimilars) under the HMSA Medicare Advantage prescription benefit as administered by CVS Caremark; it affects prescribers, pharmacies, and CVS Caremark specialty program staff handling authorization for these medications.
No material clinical or coverage changes in this revision.
Coverage Criteria for Denosumab (Xgeva and Biosimilars)
Form-based clinical criteria
Authorization assessment is guided by these clinician-provided responses on the form:
Form questions
1. Current denosumab treatment
- Is the patient currently receiving treatment with a denosumab product?
Required: Yes or No
If YES → follow-up diagnosis and benefit assessment
- What is the patient's diagnosis?
Select one: Prevention of skeletal related events (multiple myeloma or bone metastases from solid tumor such as breast, non-small cell lung, thyroid carcinoma, kidney, prostate), Palliative care for bone metastases from thyroid carcinoma, Giant cell tumor of the bone, Hypercalcemia of malignancy, Treatment of osteopenia/osteoporosis due to systemic mastocytosis, Other (if Other, no further questions)
- Is the patient receiving benefit from therapy (defined as disease stability or improvement)?
Required: Yes or No; response captured for utilization assessment
- Is Xgeva being used to treat hypercalcemia of malignancy?
If Yes → No further questions
If NO → initial diagnosis capture
- What is the patient's diagnosis?
Select one: Prevention of skeletal related events (multiple myeloma or bone metastases from solid tumor such as breast, non-small cell lung, thyroid carcinoma, kidney, prostate), Palliative care for bone metastases from thyroid carcinoma, Treatment for osteopenia or osteoporosis in a patient with systemic mastocytosis, Giant cell tumor of the bone, Hypercalcemia of malignancy, Other (No further questions)
- Attestation
Prescriber or authorized signature and date attesting information is accurate and that supporting documentation is available for review by CVS Caremark or the benefit plan sponsor.
Coding and Dosing References
| Form requests the prescriber supply the ICD-10 code relevant to the indication |
Prior Authorization Submission and Clinical Questions
Submit signed PA form by fax to CVS Caremark (include attestations and supporting documentation)
Complete the CVS Caremark prior authorization form, include required attestations, and fax it to CVS Caremark at the toll-free number. The form must be returned with the prescriber or authorized signature attesting that the information is accurate and that supporting documentation is available for review. If you have questions about the authorization, contact CVS Caremark at the local Specialty Programs number provided.
- Fax the completed form to CVS Caremark toll-free: 1-866-237-5512.
- Include prescriber or authorized signature and date to attest accuracy and availability of supporting documentation.
- For authorization questions contact CVS Caremark at 1-808-254-4414.
Definitions Relevant to This Policy
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