Added age range for metastatic melanoma and length of approval. Added covered indications of cutaneous melanoma, small cell lung cancer and non-small cell lung cancer.
Updated to note diagnosis of endometriosis must be confirmed. Added prerequisite drug therapy that must be tried.
BI618 New
Copiktra
06/01/19
Used to treat different types of leukemia and lymphoma; specialty drug--must be obtained through a contracted specialty pharmacy.
BI619 New
Elzonris
06/01/19
Requires pre-authorization; used to treat a very rare condition known as blastic plasmacytoid dendritic cell neoplasm (BPDCN). Covered under medical benefit but currently no HCPC.
BI620 New
Inbrija
06/01/19
Requires pre-authorization; inhaled formulation used to treat OFF episodes in patients diagnosed with Parkinson's Disease. Covered under pharmacy benefit.
Coming Amendments
Medical Policy Number
Medical Policy Name
Effective Date of Change
Description of Changes
BI496 V
PCKSK9 Inhibitors
07/01/19
Updated to remove specialty drug classification and to add coverage of Praluent.
For urgent questions about QualChoice Medical Coverage Policies, please fax a completed Predetermination Request Form for each patient to 844.501.2830.