Drug Indications

Policy ID: I-9002-005

Section: Injections

Effective Date: July 01, 2018

Revised Date: May 18, 2023

Revision Effective Date: July 01, 2023

Last Reviewed: May 23, 2023

Applies To: Commercial Only

Description

Blue Cross Blue Shield of North Dakota recognizes the following drug compendium as authoritative sources for use in the determination of a medically-accepted indication of drugs and biologicals used off-label. New uses for approved products that are not reflected in a product's labeling are often discovered after marketing. Before a pharmaceutical manufacturer may include any new indications in the labeling for a particular drug it must obtain the government's approval for the uses. Such approval requires the completion of adequate and well-controlled clinical trials to document the drug's safety and efficacy for the new uses. Manufacturers, in some cases, may not seek or obtain approval of new uses since there may not be sufficient economic incentive for the product sponsor to perform the necessary research or to make application to the regulatory agency.

Merative ^TM Health Micromedex®
Reviewed by international experts, DRUGDEX evidence-based documents cover FDA-approved and investigational prescription and nonprescription drugs, as well as non-U.S. preparations.
National Comprehensive Cancer Network
The National Comprehensive Cancer Network (NCCN), a not-for-profit alliance of 33 of the world's leading cancer centers devoted to patient care, develops resources that present valuable information to the numerous stakeholders in the health care delivery system. As the arbiter of high-quality cancer care, NCCN promotes the importance of continuous quality improvement and recognizes the significance of creating clinical practice guidelines appropriate for use by patients, clinicians, and other health care decision-makers.

Criteria

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.

If a medical policy specific to a drug does not exist:
Merative Health Micromedex® or the National Comprehensive Cancer Network (NCCN) Guidelines can be used as a reference to determine FDA approval of a drug or accepted, off-label indications. Benefits will be allowed for either Accepted FDA approved indications or Accepted off-label indications from either of these sources. The Micromedex Strength of Recommendation Class I or Class IIa will be considered an allowable indication for off-label indications. NCCN Guidelines with a Category 2A level of evidence and consensus or above will be considered an allowable indication for off-label use.

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020 Annual Review,

Updated Micromedex name, and
Updated NCCN description

Internal Medical Policy Committee 5-20-2021 Annual Review,

Updated NCCN description

Internal Medical Policy Committee 5-24-2022 Annual review,

Updated NCCN description

Internal Medical Policy Committee 5-23-2023 Annual review,

Updated Micromedex name from IBM Watson to Merative, and
Updated NCCN description

Links

Not Applicable

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: I-9002-004

Section: Injections

Effective Date: July 01, 2018

Revised Date: May 21, 2022

Revision Effective Date: July 01, 2022

Last Reviewed: May 24, 2022

Archived Date: June 30, 2023

Applies To: Commercial Only

Description

Blue Cross Blue Shield of North Dakota recognizes the following drug compendia as authoritative sources for use in the determination of a medically-accepted indication of drugs and biologicals used off-label. New uses for approved products that are not reflected in a product’s labeling are often discovered after marketing. Before a pharmaceutical manufacturer may include any new indications in the labeling for a particular drug it must obtain the government’s approval for the uses. Such approval requires the completion of adequate and well-controlled clinical trials to document the drug’s safety and efficacy for the new uses. Manufacturers, in some cases, may not seek or obtain approval of new uses since there may not be sufficient economic incentive for the product sponsor to perform the necessary research or to make application to the regulatory agency.

IBM Watson Health Micromedex®
Reviewed by international experts, DRUGDEX evidence-based documents cover FDA-approved and investigational prescription and nonprescription drugs, as well as non-U.S. preparations.
National Comprehensive Cancer Network
The National Comprehensive Cancer Network (NCCN), a not-for-profit alliance of 32 of the world’s leading cancer centers devoted to patient care, develops resources that present valuable information to the numerous stakeholders in the health care delivery system. As the arbiter of high-quality cancer care, NCCN promotes the importance of continuous quality improvement and recognizes the significance of creating clinical practice guidelines appropriate for use by patients, clinicians, and other health care decision-makers.

Criteria

Coverage is subject to the specific terms of the member’s benefit plan.

If a medical policy specific to a drug does not exist:
IBM Watson Health Micromedex^® or the National Comprehensive Cancer Network (NCCN) Guidelines can be used as a reference to determine FDA approval of a drug or accepted, off-label indications. Benefits will be allowed for either Accepted FDA approved indications or Accepted off-label indications from either of these sources. The Micromedex Strength of Recommendation Class I or Class IIa will be considered an allowable indication for off-label indications. NCCN Guidelines with a Category 2A level of evidence and consensus or above will be considered an allowable indication for off-label use.

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020 Annual Review, updated Micromedex name and NCCN description

Internal Medical Policy Committee 5-20-2021 Annual Review, updated NCCN description

Internal Medical Policy Committee 5-24-2022 Annual review, updated NCCN description

Links

Not Applicable

Disclaimer

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