Empire Blue Cross Blue Shield - Empire News - Winter 2008 News

Injectable drug update
The following policy updates will be effective for all claims
processed on or after March 20, 2009, regardless of the date
of service. In addition to current policy the following updates
and processing changes will be applied.

IMPORTANT make note of Policy Updates on page 15

Palonosetron HCl (J2469) — Claims reporting diagnosis V58.12 will be
reviewed for criteria: Diagnoses 995.2 and V66.2 will be considered not
medically appropriate.

Bortezomib (J9041) — Claims reporting diagnoses 200.20-200.28,
202.80 will be reviewed for criteria.

Pemetrexed Disodium (J9305) — Claims reporting diagnosis 162.0 will be
reviewed for criteria.

Rituximab (J9310) — Claims reporting diagnosis 287.4 will be considered
not medically appropriate: 287.4.

Fulvestrant (J9395) — Claims reporting diagnosis 175.0-175.9 will be
reviewed for criteria: 175.0-175.9.

Zoledronic acid (Zometa) (J3487) — Claims reporting diagnoses 200.00-
202.98, 203.10-203.82, 204.00-208.91 will be reviewed for criteria