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

The site you are transferring to is not hosted by WHA. WHA's Terms of Use and internet Privacy Practices do not apply to your use of this linked site. Please review the policies on privacy and terms of use for the linked site. WHA does not control the accuracy, completeness, or timeliness of the content on the linked site.

Press Esc to cancel

El sitio Web al que está siendo transferido no es provisto por WHA. Las Condiciones de Uso y las Prácticas de Privacidad en Internet de WHA no se aplican a este sitio Web asociado que usted está usando. Revise las políticas sobre la privacidad y condiciones de uso de este sitio Web asociado. WHA no tiene control sobre la exactitud, la totalidad o la actualidad del contenido del sitio Web asociado. WHA no puede garantizar que los servicios de traducción de idiomas estarán disponibles en el sitio vinculado.

Presione «Esc» para cancelar