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Provider Quick Alert

December 1, 2020
Review all Medical Coverage Policies at QualChoice.com.
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
BI189  V
Gastric Pacemaker11/01/20Removed reference to product no longer available; added missing code.
BI318  C
Cardiac Event Recorder, Implantable Loop Recorder11/01/20Added CPT 93365 as covered.
BI372  V,C
Women's Preventive Health Benefit11/01/20Removal of contraceptive devices is covered without member cost share.
BI566  V
Opioid Therapy for Chronic Pain & Short Acting Opioid Limits11/01/20Clarified limits not applied if being used to treat terminal illness or for end-of-life care.
BI144  V
Orencia12/01/20Added Tremfya as prerequisite drug option for psoriatic arthritis.
BI362  V
Kalydeco12/01/20Updated age limit to 4 months or older.
BI371  V
Xyrem12/01/20Updated age range to 7 years or older.
BI401  V
Xeljanz12/01/20Added Tremfya as prerequisite drug option for psoriatic arthritis. Added coverage criteria for polyarticular juvenile idiopathic arthritis.
BI522  V
Taltz12/01/20Added Tremfya as prerequisite drug option for psoriatic arthritis and added criteria for coverage for nrx-SpA.
BI555  V
Bavencio12/01/20Updated to include coverage criteria for renal cell carcinoma.
BI556  V
Imfinizi12/01/20Updated to include coverage criteria for extensive stage small cell lung cancer (ES-SCLC).
BI568  V
IL-23 Antagonists12/01/20Added coverage criteria for psoriatic arthritis for Tremfya.
BI576  V
Trelegy Ellipta12/01/20Added coverage criteria for asthma.
BI582  V
Crysvita12/01/20Updated age range to 6 months or older.
Coming Amendments

Medical Policy Number
 Medical Policy Name Effective Date of Change Description of Changes
BI666 New
Kymriah01/01/21Used to treat B-cell precursor acute lymphoblastic leukemia and diffuse large B-cell lymphoma; requires pre-authorization.
BI667 New
Tecartus01/01/21Used to treat large B-cell lymphoma; requires pre-authorization.
BI668 New
Yescarta01/01/21Used to treat large B-cell lymphoma; requires pre-authorization.
BI669 New
Zolgensma01/01/21Used to treat spinal muscular atrophy (SMA) in patients less than 2 years old. Specialty medication covered under the medical benefit; requires pre-authorization.
Immunization Coverage02/01/21Clarified distinction between routine coverage of pediatric/adolescent Hep B vaccination (19 and under) and adult Hep B vaccination (20 and over).
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.
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