Updated to include coverage criteria for Lampit (nifurtimox).
Alkindi is used to treat pediatric patients with adrenocortical insufficiency and it is covered under the pharmacy benefit as a specialty drug. Alkindi (hydrocortisone) Sprinkle requires pre-authorization.
Gamifant is used to treat primary hemophagocytic lymphohistiocytosis (HLH) in adult and pediatric patients with refractory, recurrent, or progressive disease or intolerance with conventional HLH therapy. It is an injectable medication covered under the medical benefit as a specialty drug and requires pre-authorization.
Gavreto is used to treat patients with metastatic RET fusion-positive non-small cell lung cancer (NSCLC) as detected by an approved test. It is an oral specialty medication covered under the pharmacy benefit and requires pre-authorization.
Updated age requirement for chronic idiopathic urticarial to 12 and older.
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.