XGEVA (denosumab)

XGEVA (denosumab)

OFFICE ADMINISTRATION

Indications for Prior Authorization:

• Prevention of skeletal-related events in bone metastases from solid tumors
• Treatment of giant cell tumor of bone
• Hypercalcemia of malignancy, refractory

Prior Authorization/Medical Review is required for the following condition(s):

All requests for Xgeva (denosumab) must be sent for clinical review and receive authorization prior to drug administration or claim payment.

Hypercalcemia of malignancy

• Diagnosis of hypercalcemia of malignancy, AND
• Inadequate response, intolerance, or contraindication to intravenous bisphosphonate therapy given 7 to 30 days prior to the initiation of Xgeva (denosumab)
• Covered Doses: up to 120 mg SC every 4 weeks with additional doses given on days 8 and 15 of the first month of therapy

Prevention of skeletal-related events in bone metastases

• Diagnosis of bone metastases from solid tumors, AND
• Documentation of metastatic bone disease by scan or x-ray
• Covered Doses: up to 120 mg SC every 4 weeks

Treatment of giant cell tumor in bone

• Patient is > 18 years of age OR an adolescent whose bones have matured, AND
• Tumor is unresectable or resection is likely to result in severe morbidity
• Covered Doses: up to 120 mg SC every 4 weeks with additional doses given on days 8 and 15 of the first month of therapy

This Medication is NOT COVERED for the following condition(s):

• Any indication not listed in this policy