Medical Policy Updates - December 2018

Provider Quick Alert

November 30, 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
BI010	Flu Immunizations	09/01/18	Only recombinant and unspecified vaccines are considered non-standard. Removed pre-authorization for antibiotic-free flu shots.
BI345	Testing for Drugs of Abuse	10/01/18	Aligned quantity limits with standard (once daily) NCCI edits.
BI031	Against Medical Advice	11/01/18	Care for complications resulting from a discharge against medical advice is not covered. Aligned verbiage with plan document verbiage.
BI101	Cartilage Transplants	11/01/18	MACI is covered for patellar defects.
BI198	Diabetic Shoes and Shoe Inserts	12/01/18	Clarified limits: Shoes--two (2) pairs or a combined total 4 units per year if under 18 years of age; otherwise, one (1) pair or a combined total 2 units per year. Custom molded shoe inserts--two (2) pairs or a combined total 4 units per year.
BI322	Applied Behavior Analysis	12/01/18	Clarified lower age limit to include treatment in pre-school with POS modification. Age 2-6: no POS restriction. School-age: POS is not covered (separate policy - state designated). Example: Office at a school campus location.

Coming Amendments

Medical Policy Number	Medical Policy Name	Effective Date of Change	Description of Changes
BI165	Multiple Sclerosis	01/01/19	Updated criteria for coverage of Ocrevus in RRMS and PPMS.
BI197	Zolinza	01/01/19	Added step therapy requirement through Poteligeo.
BI313	Dificid	01/01/19	Updated step therapy requirement of only one course of vancomycin. Eliminated metronidazole as step therapy option.
BI391	Factor Products	01/01/19	Added Jivi to policy (no code currently).
BI406	Xtandi	01/01/19	Added criteria for approval to treat non-metastatic castration-resistant prostate cancer.
BI423	GLP-1 Agonists	01/01/19	Added Ozempic to coverage policy.
BI473	Bariatric Surgery-CHI	01/01/19	CHI Only -- Upper age limit on bariatric surgery removed effective 1/1/2019. Updated codes for nutritional counseling and the corresponding increments.
BI479	Lynparza	01/01/19	Updated to include maintenance treatment of recurrent ovarian, fallopian tube, or primary peritoneal cancer in patients with complete or partial response to platinum-based chemo.
BI532	Hereditary Angioedema	01/01/19	Added Takhzyro to coverage policy.
BI568	IL-23 Antagonists (Name Change from Tremfya)	01/01/19	Added Ilumya to coverage policy.
BI591	Dupixent - NEW	01/01/19	Dupixent is used to treat moderate-to-severe atopic dermatitis.
BI592	Erleada - NEW	01/01/19	Oral specialty drug used to treat prostate cancer, covered under pharmacy benefit. Must be obtained through a contracted specialty pharmacy.
BI593	GI Drugs - NEW	01/01/19	Linzess--used to treat chronic constipation and irritable bowel syndrome with constipation (IBS-C). Movantik and Symproic--used to treat opioid-induced constipation (OIC). Amitiza--used to treat opioid-induced constipation (OIC) and irritable bowel syndrome with constipation (IBS-C). All require pre-authorization.
BI594	Mektovi, Braftovi - NEW	01/01/19	Mektovi (binimetinib) and Braftovi (encorafenib)--Specialty drugs covered under the pharmacy benefit, used in combination to treat unresectable or metastatic melanoma. Must be obtained through a contracted specialty pharmacy. Both require pre-authorization.
BI595	Orilissa - NEW	01/01/19	Orilissa (elagolix)--Used to treat endometriosis, requires pre-authorization.
BI596	Poteligeo - NEW	01/01/19	Poteligeo (mogamulizuma)b--Used to treat rare forms of non-Hodgkin's lymphoma (NHL). Considered a specialty drug; covered under the medical benefit. Requires pre-authorization.
BI597	Tibsovo - NEW	01/01/19	Tibsovo (ivosodenib)--Used to treat relapsed or refractory acute myelogenous leukemia (AML). Oral specialty medication; must be obtained through a contracted specialty pharmacy. Requires pre-authorization.

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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