BCBS Louisiana Medical Policy Updates – January 2019

January 2019 BCBS Louisiana Medical Policy Updates: 

• adalimumab (Humira)
• Allogeneic Hematopoietic Cell Transplantation for Genetic Diseases and Acquired Anemias
• Amniotic Membrane and Amniotic Fluid Injections
• apremilast (Otezla)
• Augmentative and Alternative Communication Devices
• Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
• Automatic Implantable Cardioverter Defibrillator (AICD)
• Axial Lumbosacral Interbody Fusion
• Baroreflex Stimulation Devices
• benralizumab (Fasenra)
• Beta Adrenergic Antagonists and Beta Adrenergic Antagonist/Diuretic Combination Drugs
• Beta Amyloid Imaging with Positron Emission Tomography (PET) for Alzheimer Disease
• Bioengineered Skin and Soft Tissue Substitutes
• Botulinum Toxins
• Branded Dexamethasone Packs
• brodalumab (Siliq)
• burosumab (Crysvita )
• burosumab (Crysvita )
• Cardiac Hemodynamic Monitoring for the Management of Heart Failure in the Outpatient Setting
• Cardiovascular Risk Panels
• cerliponase alfa (Brineura)
• certolizumab pegol (Cimzia)
• Chelation Therapy
• Chimeric Antigen Receptor T cell Therapy (CAR-T)
• Circulating Tumor DNA Management of Non-Small Cell Lung Cancer (Liquid Biopsy)
• Computed Tomography to Detect Coronary Artery Calcification
• Computer-Aided Evaluation of Malignancy with Magnetic Resonance Imaging of the Breast
• Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid
• Continuous Passive Motion (CPM)
• Corneal Collagen Cross-linking
• Coronary Computed Tomography Angiography With Selective Noninvasive Fractional Flow Reserve
• Cryosurgery Ablation of Miscellaneous Solid Tumors other than Liver or Prostate Tumors or Breast Fibroadenomas
• dalfampridine (Ampyra)
• Deep Brain Stimulation
• Dermatologic Applications of Photodynamic Therapy
• dextromethorphan/quinidine (Nuedexta )
• Dipeptidyl Peptidase-4 (DPP-4) Inhibitors, DPP-4 Inhibitor Combination Drugs, Cycloset (bromocriptine)
• DNA-Based Testing for Adolescent Idiopathic Scoliosis
• edaravone (Radicava)
• Electrostimulation and Electromagnetic Therapy for Treating Wounds
• eltrombopag (Promacta )
• emicizumab (Hemlibra)
• Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms)
• Erythropoiesis-Stimulating Agents (ESA’s): epoetin alfa (Epogen and Procrit), darbepoetin alfa (Aranesp), and pegylated epoetin beta (Mircera)
• eteplirsen (Exondys 51)
• Ethacrynic Acid Oral Products (Edecrin , generics)
• Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
• Extracranial Carotid Angioplasty/Stenting
• Facet Radiofrequency Denervation
• Focal Treatments for Prostate Cancer
• Formulary Exception Process/Non-Formulary Drug Review Process Standard Criteria (Closed Formulary)
• Functional Magnetic Resonance Imaging of the Brain
• Functional Neuromuscular Electrical Stimulation
• Gene Expression-Based Assays for Cancers of Unknown Primary
• Gene Therapy for Inherited Retinal Dystrophy
• Genetic Cancer Susceptibility Panels Using Next Generation Sequencing
• Genetic Testing for Duchenne and Becker Muscular Dystrophy
• Genetic Testing for Facioscapulohumeral Muscular Dystrophy
• Genetic Testing for Familial Cutaneous Malignant Melanoma
• Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (BRCA1/BRCA2)
• Genetic Testing for Hereditary Hearing Loss
• Genetic Testing for Inherited Thrombophilia
• Genetic Testing for Limb-Girdle Muscular Dystrophies
• Genetic Testing for Rett Syndrome
• Genetic Testing in the Evaluation of Patients With Stable Ischemic Heart Disease
• Genetic Testing of CADASIL Syndrome
• GLP-1 Agonists for Diabetes
• golimumab (Simponi Aria, Simponi)
• Hematopoietic Cell Transplantation for Autoimmune Diseases
• Hematopoietic Cell Transplantation for Miscellaneous Solid Tumors in Adults
• Hyperbaric Oxygen Pressurization (HBO)
• Immune Globulin Therapy
• Immune Prophylaxis for Respiratory Syncytial Virus
• Implantable Sinus Stents for Postoperative Use Following Endoscopic Sinus Surgery and for Recurrent Sinus Disease
• Interferon gamma-1B (Actimmune)
• Intra-articular Hyaluronan Injections for Osteoarthritis of the Knee
• Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain
• Intracellular Micronutrient Analysis
• Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease
• Intravitreal Corticosteroid Implants
• ixekizumab (Taltz)
• Laboratory Tests for Heart Transplant Rejection
• lanadelumab-flyo (Takhzyro )
• Liver Transplant and Combined Liver-Kidney Transplant
• Lung and Lobar Lung Transplant
• Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer
• Magnetoencephalography/Magnetic Source Imaging
• methergine/methylergonovine tablets
• migalastat (Galafold )
• Molecular Analysis for Targeted Therapy of Non-Small-Cell Lung Cancer
• Molecular Panel Testing of Cancers to Identify Targeted Therapies
• Myoelectric Prosthetic Components for the Upper Limb
• Next-Generation Sequencing for the Assessment of Measurable Residual Disease
• Ophthalmic Prostaglandins
• parathyroid hormone (Natpara )
• Pharmacotherapy for Gaucher Disease
• Pheochromocytoma Medications (Demser , Dibenzyline , generics)
• Progenitor Cell Therapy for the Treatment of Damaged Myocardium due to Ischemia
• Prophylactic Mastectomy
• Quantitative Assay for Measurement of HER2 Total Protein Expression and HER2 Dimers
• Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder
• Restasis  (cyclosporine ophthalmic)
• Retinal Telescreening for Diabetic Retinopathy
• Rhopressa  (netarsudil ophthalmic)
• riluzole (Tiglutik )
• rituximab (Rituxan), rituximab and hyaluronidase, human (Rituxan Hycela)
• sarilumab (Kevzara)
• Saturation Biopsy for Diagnosis, Staging, and Management of Prostate Cancer
• secukinumab (Cosentyx)
• Select Anti-Epileptic Drugs
• Select Drug Quantity Management
• Select Oral Oncology Drugs
• Sensipar  (cinacalcet)
• Sex Reassignment Surgery
• Sodium-Glucose Co-Transporter-2 (SGLT-2) Inhibitors and Combination Products
• Subtalar Arthroereisis
• Temporomandibular Joint Dysfunction
• Therapeutic Radiopharmaceuticals in Oncology
• tildrakizumab-asmn (Ilumya™)
• tofacitinib (Xeljanz/Xeljanz XR)
• Topical Acne Products
• Topical and Nasal Testosterone Products
• Topical Antipruritics
• Transcatheter Pulmonary Valve Implantation
• triamcinolone extended release intra-articular injection (Zilretta)
• Urea Cycle Disorder Pharmacologic Agents (Buphenyl , Ravicti , generics)
• ustekinumab (Stelara)
• Vagus Nerve Stimulation
• Vertebral Axial Decompression
• vestronidase alfa-vjbk (Mepsevii)
• vigabatrin (Sabril)
• Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders
• Wireless Capsule Endoscopy to Diagnose Disorders of the Small Bowel, Esophagus, and Colon

Click here to view the Blue Cross Blue Shield Louisiana Medical Policy Updates »

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