Medical Policy Number
|
Medical Policy Name |
Effective Date of Change |
Description of Changes |
BI038 |
Genetic Testing |
01/01/18 |
Added coverage for myPath Melanoma test.
|
BI049 |
Hearing Aids |
01/01/18 |
Added pre-authorization requirement if hearing aid is needed more than once every 3 years. |
BI109 |
Out-of-Network |
01/01/18 |
Added new permission from AID concerning elective services of out-of-network providers. |
BI129 |
Tumor Markers |
01/01/18 |
Added Z85.3 (personal history of breast cancer) as a covered diagnosis for testing CEA (82738). |
BI143 |
Enbrel |
02/01/18 |
Changed prerequisite on therapy for psoriasis. |
BI162 |
Urinary Incontinence Treatments |
01/01/18 |
Removed Oxytrol from covered products. |
BI217 |
Orthotic Devices and Orthotic Services |
02/01/18 |
Clarified pre-authorization need for orthotic management/training codes. |
BI261 |
Simponi |
01/01/18 |
Added psoriatic arthritis and ankylosing spondylitis as approved indications for Simponi Aria for covered indications. |
BI306 |
Obstructive Sleep Apnea |
02/01/18 |
Added IDTF accreditation requirement language for home sleep testing. |
BI342 |
Nutritional Counseling in Chronic Disease |
01/01/18 |
Will be approved without pre-authorization as long as the appropriate diagnosis is used. Any diagnoses other than what is listed in BI will require pre-authorization. Added cleft palate language. |
BI380 |
Relistor |
02/01/18 |
Updated criteria to require 60-day trial of Movantik. |
BI381 |
Intraoperative Neurophysiologic Monitoring |
02/01/18 |
Documentation requirement clarified for professional component of intraoperative neurophysiologic monitoring. Added out-of-network verbiage. |
BI383 |
Bio-Engineered Soft Tissue Substitutes as Implants |
01/01/18 |
Updated procedure codes for coverage of biologic implants. |
BI424 |
Osphena |
01/01/18 |
Updated to add Intrarosa to coverage policy. |
BI439 |
Transcranial Magnetic Stimulation |
01/01/18 |
Request for TMS requires failure of at least three different drug regimens from two different drug classes. Pre-authorization request requires clinical documentation of drug treatment failures over the previous 18 months of treatment. |
BI454 |
Otezla |
01/01/18 |
Updated perequisite therapy to only one DMARD. |
BI464 |
Urinary Antispasmodics |
01/01/18 |
Removed pre-authorization requirement for tolterodine ER and removed Oxytrol from coverage. |
BI482 |
Hepatitis C |
01/01/18 |
Added coverage/dosing criteria for Mavyret and Vosevi. Deleted coverage of Zepatier. |
BI483 |
Cosentyx |
01/01/18 |
Updated prerequisite therapy for psoriasis, psoriatic arthritis, and ankylosing spondylitis. |
BI521 |
Orfadin |
01/01/18 |
Removed Orfadin from coverage and added NITYR. |
BI522 |
Taltz |
02/01/18 |
Updated prerequisite therapy to include Tremfya and Cosentyx. |
BI526 |
Zurampic |
01/01/18 |
Added Duzallo to policy. |
BI532 |
Hereditary Angioedema Treatment |
01/01/18 |
Added Haegarda to coverage policy. |
BI562 |
Besponsa |
01/01/18 |
New drug used to treat a type of leukemia. Pre-authorization is required. Covered under the medical benefit as a specialty drug. |
BI563 |
IDHIFA |
01/01/18 |
New drug used to treat a type of leukemia. Pre-authorization is required. Covered under the medical benefit as a specialty drug. |
BI564 |
Kevzara |
01/01/18 |
New drug used to treat rheumatoid arthritis. Pre-authorization is required. Covered under the pharmacy benefit as a specialty drug. |
BI565 |
Nerlynx |
01/01/18 |
New drug used to treat breast cancer. Pre-authorization is required. Oral specialty medication covered under the pharmacy benefit. Must be obtained from a contracted specialty pharmacy. |
BI567 |
Syndros |
01/01/18 |
New drug used to treat chemotherapy-induced nausea/vomiting. Oral solution requires pre-authorization. Covered under the pharmacy benefit. |
BI568 |
Tremfya |
01/01/18 |
New drug used to treat moderate to severe psoriasis. Pre-authorization is required. Covered under the pharmacy benefit as a specialty drug. |
BI569 |
Vyxeos |
01/01/18 |
New drug used to treat a type of leukemia. Pre-authorization is required. Covered under the medical benefit as a specialty drug. |