Denosumab (Xgeva)

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


 

Last review date: July 21, 2016