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Medical Policy Implementation: Radium Ra 223 dichloride (Xofigo)

Effective October 17, 2016, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider claims for Xofigo®.

Our revised medical policy, Radium Ra 223 dichloride (Xofigo), identifies when the use of Xofigo would be considered medically necessary or investigational.

We encourage you to review this policy in our Medical Policy Manual.

Based on the guidelines of our revised medical policy, Radium Ra 223 dichloride (Xofigo) AND the submitted diagnosis code(s):

  • HCPCS code A9606 submitted on claims for services provided on and after October 17, 2016 to male patients (regardless of patient age) may be denied as an investigational service.
  • Claims that include HCPCS code A9606 for services provided on and after October 17, 2016 to male patients 18 years of age and older may pend while we request information to help us determine if the use of this drug is to be considered medically necessary or investigational.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after October 17, 2016.

This document contains references to brand name prescription medicines that are trademarks or registered marks of pharmaceutical manufacturers that are not affiliated with Horizon Blue Cross Blue Shield of New Jersey or the Blue Cross and Blue Shield Association.

Published on: July 18, 2016, 09:16 a.m. ET
Last updated on: November 25, 2020, 00:30 a.m. ET