Provider Quick Alert

April 1, 2019
Review all  Medical Coverage Policies at QualChoice.com.

New and Amended Medical Policies
P = Payment Change
C = Code Change
V = Verbiage Change

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI062   C, V
Preventive Health Benefit 01/01/19
1) Clarified CRC screening, 2) Addressed coverage of Cologuard w/diagnosis 79.01 and 3) Added Dx for dense tissue to allow breast U/S as screening/preventive. 
BI099   V
Interferons
04/01/19
Added coverage criteria for Sylatron.
BI165   V
Multiple Sclerosis 04/01/19 Updated coverage criteria for Ocrevus in RRMS to require t/f of at least two preferred products.
BI315
Sylatron 04/01/19 Retired policy.
BI444
Trokendi XR 04/01/19 Retired policy.
BI480  V
Opdivo 04/01/19 Updated to include reference to using Opdivo as first-line treatment in advanced RCC in combination with Yervoy.
BI484  V
Ibrance
 04/01/19 Added reauthorization criteria.
BI485   V
Lenvima
04/01/19
Added coverage criteria for advanced renal cell cancer and unresectable hepatocellular carcinoma.
BI524   V
Venclexta 04/01/19 Updated to include coverage for SLL, MCL, and AML.
BI583   V
Long Acting Opioids
04/01/19
Updated reauthorization criteria.
BI585   V
Aimovig 04/01/19
Updated title to Calcitonin Gene Related Peptide (CGRP) Inhibitors and added coverage criteria for Emgality along with Aimovig. Noted Ajovy is not covered. Removed requirement for triptan use.
BI603   New
Aemcolo 04/01/19 Used to treat travelers' diarrhea caused by noninvasive strains of Escherichia coli in adults. Covered under the pharmacy benefit.
BI604   New
Arikayce 04/01/19
Used to treat a complex lung condition caused by a particular bacteria after other standard treatments have failed. Specialty drug covered under the pharmacy benefit.
BI605   New
Cequa 04/01/19 Used to treat keratoconjunctivitis sicca (dry eye). Covered under the pharmacy benefit.
BI606   New
Daurismo 04/01/19
Used to treat leukemia. Oral specialty drug covered under the pharmacy benefit; must be obtained through a contracted specialty pharmacy.
BI607   New
Epidolex 04/01/19 Used to treat seizures associated with Dravet syndrome or Lennox-Gastaut syndrome. Covered under the pharmacy benefit.
BI608   New
Lorbrena 04/01/19
Used to treat lung cancer. Oral specialty drug covered under the pharmacy benefit; must be obtained through a contracted specialty pharmacy.
BI609   New
Lumoxiti 04/01/19 Used to treat hairy-cell leukemia. Specialty drug covered under the medical benefit.
BI610   New
Luxturna 04/01/19
Used to treat patients with confirmed biallelic RPE65 mutation-associated retinal dystrophy. Covered under the medical benefit.
BI611   New
Oxervate
 04/01/19 Used to treat advanced cases of neurotrophic keratitis (NK).
BI612   New
Talzenna 04/01/19
Used to treat advanced or metastatic breast cancer. Oral specialty drug covered under the pharmacy benefit; must be obtained through a contracted specialty pharmacy.
BI613   New
Ultomiris 04/01/19 Used to treat paroxysmal nocturnal hemoglobinuria (PNH). Specialty drug covered under the medical benefit.
BI614   New
Viktravi 04/01/19
Used to treat adults and pediatrics with solid tumors that have a neurotrophic receptor tyrosine kinase (NTRK) gene fusion. Not used to treat a specific cancer. Oral specialty drug covered under the pharmacy benefit; must be obtained through a contracted specialty pharmacy.
BI615   New
Vizimpro 04/01/19 Used to treat lung cancer. Specialty drug covered under the pharmacy benefit; must be obtained through a contracted specialty pharmacy.
BI616   New
Xospata 04/01/19
Used to treat a type of leukemia. Oral specialty drug covered under the pharmacy benefit; must be obtained through a contracted specialty pharmacy.
For urgent questions about QualChoice Medical Coverage Policies, please fax a completed
Predetermination Request Form for each patient to 844.501.2830.
1903 MK 013