CurrentHighmark Blueshield NenyPolicy N/A

Outpatient Medical Injectable Rituximab and Biosimilars Request Form

A faxed medical-benefit prior authorization / request form for outpatient injectable rituximab products and biosimilars used by Highmark Blue Shield NENY to collect clinical and administrative information (member, provider, diagnosis, indication-specific questions) and to document trials of preferred products when non-preferred agents are requested.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Medical Injectable Rituximab and Biosimilars Request Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage change)

Effective Date

Next Review Date

Key ActionProviders must complete and fax the Outpatient Medical Injectable Rituximab and Biosimilars Request Form to 833-619-5745 to request medical-benefit coverage for rituximab products or biosimilars.

POLICY UPDATE CHANGES

No material clinical or coverage changes.

5Non-preferred products listed

Prior trialsDocument requirement

FaxSubmission method

Policy overview

Payer: Highmark Blue Shield NENY. Subject/Title: Outpatient Medical Injectable Rituximab and Biosimilars Request Form. Coverage stance: informational. This is a faxed medical-benefit prior authorization/request form used to collect clinical and administrative information (member, provider, diagnosis, indication-specific questions) and to document trials of preferred products when non-preferred agents are requested. Providers must fax the completed form to 833-619-5745 for medical-benefit coverage requests.

Key document details

PayerHighmark Blue Shield NENY (medical-benefit prior authorization form)

Policy (subject)Outpatient Medical Injectable Rituximab and Biosimilars Request Form

StatusCURRENT

Coverage stanceInformational — form collects clinical/admin info and documents trials of preferred products when non-preferred agents are requested

Non-preferred products listed: 5Ruxience (Q5119); Rituxan (J9312); Riabni (Q5123); Truxima (Q5115); Rituxan Hycela (19311)

Non-preferred product consideration criteria

Non-preferred product consideration

Non-preferred product will be considered when ALL of the following are met:

ALL of the following

Documented failure or intolerance to preferred products
- Therapy failure to preferred products: Member has a documented therapy failure after an adequate therapeutic trial of BOTH preferred products
- Intolerance/contraindication to preferred products: Both preferred products have not been tolerated or are contraindicated
Rituxan Hycela requirement: For Rituxan Hycela: patient must have received at least one full dose of a rituximab product by intravenous infusion
Specific product-level requirement

Medicare members established on non-preferred therapy

Medicare members currently established on a non-preferred therapy are not required to try preferred option

Clinical details requested on form

Oncology-specific information requested

Form requests the following oncology clinical details to support the request:

ALL of the following

Cancer type: Type of cancer including histology and stage
Chemotherapy regimen: Member's chemotherapy regimen
Line of therapy (First, Second, Subsequent)
Previous therapies received (including whether progressed or relapsed)
CD20 status: Is the patient's disease CD20-positive? (YES / NO / NOT APPLICABLE)

Non-oncology-specific information requested

Form requests the following non-oncology clinical details to support the request:

ALL of the following

Prior medications: Medications previously used for this condition
Concomitant medications: Medications to be used in conjunction for the condition
Dose and frequency of the member's treatment (Dose / Frequency fields)

Rheumatoid arthritis specific questions

For RA indications the form requests:

ALL of the following

RA activity: Is the member's RA moderately to severely active? (YES / NO)
Start vs continuation: Is this a New Start or Continuation of Therapy
Last infusion date: Date of last infusion (date field)
Response: Has the member demonstrated disease stability or a beneficial response to therapy? (YES / NO)

What providers must do

Prior Authorization

Submit completed request form via fax

Providers must complete and fax the Outpatient Medical Injectable Rituximab and Biosimilars Request Form to 833-619-5745 to request medical-benefit coverage for rituximab products or biosimilars.

Fax number: 833-619-5745

Documentation Required

Document prior therapy and tolerability

When requesting a non-preferred rituximab product, document failure or intolerance to both preferred products or that both are contraindicated. For Rituxan Hycela, document that the patient has received at least one full prior intravenous dose of a rituximab product.

Documentation Required

Provide indication-specific clinical details

Provide indication-specific clinical details: For oncology, supply cancer type including histology and stage, the chemotherapy regimen, the line of therapy, previous therapies received (including progression/relapse), and whether the disease is CD20-positive. For non-oncology, list prior medications used for the condition, medications to be used in conjunction, and dose and frequency. For rheumatoid arthritis, include whether RA is moderately to severely active, whether this is a new start or continuation, date of last infusion, and whether the member has demonstrated disease stability or a beneficial response; attach pertinent clinical information.

Documentation Required

Verify member eligibility and benefits

Verify the member's eligibility and benefits through the health plan prior to submission.

Form purpose and use

This administrative request form gathers required clinical information to evaluate coverage for outpatient rituximab products and biosimilars under the medical benefit. It lists non-preferred products (including codes) and requires documentation of either a documented therapy failure after an adequate trial of BOTH preferred products or that BOTH preferred products are not tolerated or are contraindicated when a non-preferred agent is requested. For Rituxan Hycela, the form requires documentation that the patient received at least one full dose of a rituximab product by intravenous infusion. The form also requests oncology-specific details (cancer type/histology/stage, chemotherapy regimen, line of therapy, prior therapies, CD20 status), non-oncology details (prior and concomitant medications, dose and frequency), and RA-specific information (disease activity, new start vs continuation, date of last infusion, response, and attachments).

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient Medical Injectable Rituximab and Biosimilars Request Form

Policy CodePolicy N/A

Change TypeAdministrative form (no material coverage change)

Effective Date

Next Review Date

On This Page

OpenPayer

Outpatient Medical Injectable Rituximab and Biosimilars Request Form

Policy overview

Non-preferred product consideration criteria

Clinical details requested on form

Codes referenced on the form

What providers must do

Form purpose and use

Q5119	Ruxience
J9312	Rituxan
Q5123	Riabni
Q5115	Truxima
19311	Rituxan Hycela