Medical Policy Updates

Provider Quick Alert

June 1, 2018

Review all Medical Coverage Policies at QualChoice.com.

New and Amended Medical Policies

Medical Policy Number	Medical Policy Name	Effective Date of Change	Description of Changes
BI024	Medical Necessity Determination	05/01/18	Clarified that pre-authorization/medical necessity determination requests must come from prescribing providers rather than vendors.
BI156	ADHD	05/01/18	Removed Strattera (atomoxetine) from PA required.
BI171	Rituxan	05/01/18	Added Rituxan Hycela to coverage policy.
BI173	Alpha 1-Antitrypsin Inhibitor Therapy	05/01/18	Updated code J0256 to include Aralast.
BI301	Liver Lesion Treatments	05/01/18	Reviewed with BI298 - Consolidated duplicative policy for ablation of hepatic lesions (BI298).
BI302	Natroba	05/01/18	Retired policy.
BI453	Corticosteroid Beta Agonist Combo Products	05/01/18	Updated first-line therapy listing by removing Foradil and adding Incruse Ellipta.
BI562	Besponsa	05/01/18	Included new code C9028 for Besponsa.

Coming Amendments

Medical Policy Number	Medical Policy Name	Effective Date of Change	Description of Changes
BI359	Erwinaze	07/01/18	Added code J9019 (Injection, asparaginase, 1,000 IU) to policy.
BI391	Factor Products	07/01/18	Added code J7192 and Hemlibra (no code currently) to policy.
BI419	SGLT-2 Inhibitors	07/01/18	Updated policy to specifically list covered products, including combination products.
BI420	DPP4 Inhibitors	07/01/18	Updated policy to list specific, covered combination products in addition to single-entity products.
BI506	Nucala	07/01/18	Added that Nucala is also considered medically necessary for members > 18 years of age with a diagnosis of eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome).
BI581	Pharmacogenetic Testing	07/01/18	Pharmacogenetics testing requires pre-authorization and is the study of variability in drug response due to genetic factors. Many pharmacogenetic tests are considered experimental and investigational because their clinical utility has not been proven.
BI215	Sprycel	08/01/18	Clarified requirement that treatment of GIST requires trial of all three (3) products listed.
BI464	Urinary Antispasmodics	08/01/18	Updated criteria to reflect trial of two (2) generics before brand products are approved.
BI479	Lynparza	08/01/18	Updated to include invasive breast cancer diagnosis.
BI516	Buprenorphine - Naloxone	08/01/18	Removed PA requirement for buprenorphine/naloxone SL tablets. Updated PA criteria for Bunavail.
BI537	Rubraca	08/01/18	Updated criteria to include newly approved diagnosis for partial or complete response after platinum-based therapy.

For urgent questions about QualChoice Medical Coverage Policies, please fax a completed Predetermination Request Form for each patient to 844.501.2830.

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