CommercialAdministrativeLow impact
08.01.14e, Radium Ra 223 dichloride (Xofigo®) Injection (Independence Administrators)
Independence Blue Cross·Oncology, Pharmacy, Urology·Pharmacy
We identified it
Jun 19, 2026
Summary
This is a routine annual reissue of the Independence Administrators Xofigo® (Radium Ra 223 dichloride) policy with no substantive changes to coverage criteria, medical necessity requirements, or billing codes. The policy continues to cover a maximum of six injections for castration-resistant prostate cancer with bone metastases when specific clinical and laboratory criteria are met. Billing teams should verify member eligibility and confirm whether the member's group has enrolled in the UM vendor program, as the policy does not apply to those groups.
Action Required
No immediate action required. This is a reissue with no changes to coverage or billing requirements. Billing teams should continue standard procedures: (1) Verify individual member benefits and confirm Independence Administrators is the claims administrator and the group has NOT enrolled in the UM vendor program before processing claims; (2) Continue billing HCPCS code A9606 for Xofigo® claims; (3) Ensure prior to claim submission that clinical documentation includes: castration-resistant prostate cancer diagnosis with testosterone <50 ng/dL, documented failure of hormonal therapies, symptomatic skeletal metastases, imaging within 30 days showing no visceral metastases or bulky lymph nodes >3cm, and applicable lab values (ANC, platelet count, hemoglobin); (4) Limit coverage to maximum six injections unless off-label use is supported per Company policy. No workflow changes are required.