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Provider Quick Alert

March 21, 2022
Review all Medical Coverage Policies at
Coming Amendments

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

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI096  V
Continuous Glucoe Monitoring01/01/22Freestyle Libre and Dexcom no longer require PA under Pharmacy benefit.
BI166  V
Enzyme Replacement Therapy for Lysosomal Disorders01/01/22Updated with Nexviazyme (C9085) coverage criteria for late onset Pompe disease.
BI359  C,V
Erwinaze01/01/22Updated to include Rylaze (J9021), updated criteria for ALL, and added coverage criteria for lymphoblastic lymphoma.
BI469  C,V
Keytruda05/01/22Updated criteria for several indications and added criteria for newly approved indications.
BI688  NEW
Imlygic01/01/22New drug used to treat melanoma.
BI689  NEW
Jemperli01/01/22New drug used to treat endometrial carcinoma and solid tumors.
BI690  NEW
Margenza01/01/22New drug used to treat metastatic breast cancer.
BI691  NEW
Rybrevant01/01/22New drug used to treat lung cancer.
BI692  NEW
Saphnelo01/01/22New drug used to treat systemic lupus erythematosus (SLE).
BI693  NEW
Tivdak01/01/22New drug used to treat cervical cancer.
BI694  NEW
Zynlonta01/01/22New drug used to treat a type of lymphoma.

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.