Bezlotoxumab (ZinplavaTM) is a human monoclonal antibody used to decrease the risk of Clostridium difficile infection (CDI) from coming back in adult individuals who are at high risk of CDI recurrence.
Coverage is subject to the specific terms of the member’s benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Bezlotoxumab (Zinplava) may be considered medically necessary to reduce the recurrence of CDI in individuals who meet ALL of the following:
Bezlotoxumab (Zinplava) is considered experimental/investigational for any other indication, and, therefore, non-covered. Scientific evidence does not support its use for any other indications.
NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Blue Cross Blue Shield of North Dakota may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.
Covered Diagnosis Codes for J0565