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Archival of several medical policies

December 2, 2020

Effective January 1, 2021, the following policies will be archived because the precertification requirement for the applicable drugs will be removed:

  • Commercial: #08.01.19f: Siltuximab (Sylvant®)
  • Medicare Advantage: MA08.006f: Siltuximab (Sylvant®)
    • The code J2860 Injection, siltuximab, 10 mg is eligible for coverage.​
  • Commercial: #08.00.98e: Eribulin Mesylate (Halaven®)
  • Medicare Advantage: MA08.056c: Eribulin Mesylate (Halaven®)
    • The code J9179 Injection, eribulin mesylate, 0.1 mg is eligible for coverage.
  • Commercial: #08.00.96e: Cabazitaxel (Jevtana®)
  • Medicare Advantage: MA08.054c: Cabazitaxel (Jevtana®)
    • The code J9043 Injection, Cabazitaxel, 1 mg is eligible for coverage.

Changes to the precertification requirement list that become effective January 1, 2021, are  posted on our website.

Effective January 1, 2021, the following policies will be archived because the information in these policies is now addressed in our Cosmetic Procedures policies #12.01.03a for Commercial products and #MA12.009a for Medicare Advantage products:

  • Commercial: #08.01.24a: Deoxycholic Acid (KybellaTM)
  • Medicare Advantage: MA08.074a: Deoxycholic Acid (KybellaTM)
    • The code J0591 Injection, deoxycholic acid, 1 mg will remain a cosmetic service.

Effective January 4, 2021, the following policies will be archived:

  • Commercial: #08.00.88f: Ofatumumab (Arzerra®)
  • Medicare Advantage: MA08.048d: Ofatumumab (Arzerra®)
    • The code J9302 Injection, Ofatumumab acid, 10 mg is eligible for coverage.

Precertification information on the above policies was previously communicated in a Partners in Health UpdateSM article.


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