Clarified covered biosimilar products. Noted Q5109 (not available in U.S.) and Q5121 are not covered. Only Q5103 and Q5104 are covered biosimilar products. Service is no longer considered E&I but will be covered with pre-authorization.
Removed restriction if Darzalex was used previously.
BI656 New
Krystexxa
10/01/20
Used to treat chronic gout in adult refractory to conventional therapy. Specialty drug covered under the medical benefit; requires pre-authorization.
BI657 New
Isturisa
10/01/20
Used to treat adults with Cushing's Disease. Oral specialty medication covered under the pharmacy benefit; must be obtained through a contracted specialty pharmacy. Requires pre-authorization.
BI658 New
Koselugo
10/01/20
Used to treat children with inoperable neurofibromas. Oral specialty medication covered under the pharmacy benefit; must be obtained from a in-network specialty pharmacy. Requires pre-authorization.
BI659 New
Pemazyre
10/01/20
Used to treat adults with previously treated advanced cholangiocarcinoma. Oral specialty medication covered under the pharmacy benefit; must be obtained through an in-network specialty pharmacy. Requires pre-authorization.
BI660 New
Qinlock
10/01/20
Used for previously treated advanced gastrointestinal stroma tumor (GIST). Oral specialty medication covered under the pharmacy benefit; must be obtained from an in-network specialty pharmacy. Requires pre-authorization.
BI661 New
Retevmo
10/01/20
Used to treat certain types of non-small cell lung and thyroid cancer. Oral specialty medication covered under the pharmacy benefit; must be obtained from an in-network specialty pharmacy. Requires pre-authorization.
BI662 New
Tabrecta
10/01/20
Used to treat adults with metastaic non-small cell lung cancer. Oral specialty medication covered under the pharmacy benefit; must be obtained from an in-network specialty pharmacy. Requires pre-authorization.
BI663 New
Trodelvy
10/01/20
Used to treat adults with metastatic triple-negative breast cancer. Specialty medication covered under the medical benefit. Requires pre-authorization.
BI664 New
Tukysa
10/01/20
Used to treat a type of advanced breast cancer. Oral specialty medication covered under the pharmacy benefit; must be obtained from an in-network specialty pharmacy. Requires pre-authorization.
BI665 New
Xcopri
10/01/20
Used to treat a type of seizure in adults. Oral drug covered under the pharmacy benefit. Requires pre-authorization.
For questions about QualChoice Medical Coverage Policies, please contact your Provider Relations Representative at 800.235.7111 or 501.228.7111, ext. 7004, Monday through Friday, 8:00 a.m. to 5:00 p.m.
