Added criteria for opioid use for management of chronic pain as already listed in BI583.
BI630 New
Nubeqa
01/01/20
Used to treat non-metastatic castration resistant prostate cancer; requires pre-authorization. Oral specialty drug covered under the pharmacy benefit; must be obtained from a contracted specialty pharmacy.
BI631 New
Piqray
01/01/20
Used to treat advanced breast cancer; requires pre-authorization. Oral specialty medication covered under the pharmacy benefit; must be obtained through a contracted specialty pharmacy.
BI632New
Rinvoq
01/01/20
Used to treat rheumatoid arthritis; requires pre-authorization. Specialty drug covered under the pharmacy benefit; must be obtained from a contracted specialty pharmacy.
BI633 New
Sunosi
01/01/20
Used to improve wakefulness in adult patients with excessive daytime sleepiness (EDS) associated with narcolepsy or obstructive sleep apnea.
BI634 New
Turalio
01/01/20
Used to treat tenosynovial giant cell tumor. Oral specialty drug covered under the pharmacy benefit; must be obtained through a contracted specialty pharmacy.
BI635 New
Xpovio
01/01/20
Used to treat multiple myeloma. Oral specialty drug covered under the pharmacy benefit; must be obtained through a contracted specialty pharmacy.
BI636New
Zelnorm
01/01/20
Used to treat women under 65 years of age with irritable bowel syndrome with constipation (IBS-C).
BI637 New
Bariatric Surgery
01/01/20
New policy based on removal of exclusion criteria for large group policies beginning 1/1/2020 as plans begin or renew.
Updated policy title and referenced CDC Guideline for Prescribing Opioids for Chronic Pain. Changed criteria from trial of 2 to 3 pharmacologic agents.
For urgent questions about QualChoice Medical Coverage Policies, please fax a completed Predetermination Request Form for each patient to 844.501.2830.