01Perform a search of the State Health Plan Medical Drug Formulary for drugs administered and billed through the medical setting.
02For Dupuytren's contracture, confirm the patient is 18 or older, has a palpable cord with a contracture of at least 20 degrees in an MP or PIP joint, has functional impairment in the hand due to the contracture, and has not received surgical treatment such as fasciectomy or fasciotomy on the selected primary joint within the last 90 days.
03For Peyronie's disease, confirm the patient is 18 or older, has a palpable plaque and a curvature deformity of at least 30 degrees, the plaque does not involve the penile urethra, the patient has intact erectile function (with or without use of medications), the prescriber is a certified provider through the Xiaflex REMS Program, the patient has no FDA labeled contraindications to the requested agent, and the requested dose is within FDA labeled dosing for the indication.
04Xiaflex is available for Peyronie's disease only through the Xiaflex REMS Program, which requires provider training and certification, patient counseling on the risks of corporal rupture and other serious injuries to the penis, and restricted distribution through specially certified healthcare settings.
05Healthcare providers must give patients the Patient Counseling Tool, 'What You Need to Know About XIAFLEX Treatment for Peyronie's Disease: A Patient Guide,' after each XIAFLEX injection.
06Authorization length is 3 months for Dupuytren's contracture (3 treatment cycles) and 6 months for Peyronie's disease (4 treatment cycles).
07Services related to delivery or administration of a medication determined to be not medically necessary will also be considered not medically necessary.
08Xiaflex is considered investigational for all other indications, including adhesive capsulitis.
09BCBSMS may request medical records for determination of medical necessity, and letters of support alone are not sufficient unless all specific information needed for the determination is included.