Provider Quick Alert

May 31, 2019
Review all  Medical Coverage Policies at
New and Amended Medical Policies

P = Payment Change
C = Code Change
V = Verbiage Change

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI022   V
Immunization Coverage 01/01/19 Aligned MMR coverage for adults with CDC DOB recommendations. 
BI322   V
Applied Behavior Analysis
Aligned with Centene per AID request.
BI272   V
Obstetrical Ultrasound 05/01/19
Fetal echocardiography, fetal Doppler echocardiography and Doppler velocimetry require pre-authorization.
BI350   V
Tysabri 05/01/19 Removed reference to pre-authorization requirement every 6 months.
BI215   V
Sprycel 06/01/19
Clarified age ranges for each covered diagnosis and added coverage for bone cancer.
BI309   V
Yervoy 06/01/19 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.
BI334   V
Adcetris 06/01/19
Removed requirement for failure of at least one multi-agent chemo regimen for sALCL based on NCCN preferred treatment recommendation.
BI361   V
Updated to include first-line use with Keytruda in advanced RCC.
BI442   V
Gilotrif 06/01/19
Added approved indication of metastatic squamous NSCLC after progressing on platinum-based chemotherapy.
BI469   V
Keytruda 06/01/19 Updated criteria for advanced renal cell cancer and for expanded indications for NSCLC.
BI519   V
Empliciti 06/01/19
Added criteria for use in multiple myeloma in combination with Pomalyst.
BI526   V
Zurampic 06/01/19 Retired policy.
BI591   V
Dupixent 06/01/19
Added length of trial for prerequisite drugs for atopic dermatitis. Added approved indication of asthma with criteria.
BI595   V
Orilissa 06/01/19 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.
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