CommercialAdministrativeLow impact
08.01.14e, Radium Ra 223 dichloride (Xofigo®) Injection (Independence Administrators)
Independence Blue Cross·Oncology, Urology, Pharmacy·Pharmacy
We identified it
Jun 19, 2026
Summary
This is a reissue with no substantive changes to Independence Administrators' policy on Radium Ra 223 dichloride (Xofigo®) for castration-resistant prostate cancer. The policy maintains coverage for a maximum of six injections when specific medical criteria are met, including confirmed hormone resistance, documented hormonal therapy failure, symptomatic bone metastases, and absence of visceral metastases. No billing code, coverage criteria, or documentation requirements have changed.
Action Required
No immediate action required. This is an annual policy reissue with no changes to coverage, billing codes, medical necessity criteria, or documentation requirements. Billing teams should verify that current systems reflect the existing policy: (1) HCPCS code A9606 is correctly mapped in billing software for Xofigo® claims, (2) Claims are limited to a maximum of six injections per patient, (3) Prior to submission, verify the patient's group has NOT enrolled in the UM vendor program, as this policy does not apply to those groups as of their renewal date, and (4) All required documentation per the policy (testosterone levels <50 ng/dL, PSA progression or new bone metastases on recent imaging, hormonal therapy failure, symptomatic bone metastases, and absence of visceral metastases) is present in the medical record. No workflow changes are needed.