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
Last review date: July 21, 2016