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Provider Quick Alert

December 30, 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
BI010  C
Flu Immunization12/01/20Removed pre-authorization requirement from 90682 and 90673.
BI566  V
Opioid Therapy for Chronic Pain & Short Acting Opioid Limits12/01/20Clarified limits not applied if being used to treat terminal illness or for end-of-life care.
BI165  V
Multiple Sclerosis01/01/21Updated coverage to include Kesimpta as non-preferred product.
BI406  V
Xtandi01/01/21Updated criteria to include metastatic castration-sensitive prostate cancer (CSPC).
Aripiprazole01/01/21Retired policy.
BI591  V
Dupixent01/01/21Updated age for atopic dermatitis to 6 and older and added coverage criteria for chronic rhinosinusitis with nasal polyposis.
BI595  V
Orilissa-Oriahnn01/01/20Updated to include coverage criteria for Oriahnn.
BI650  V
Vascepa01/01/21Updated to include criteria for Cardiovascular Disease Risk reduction.
BI670  New
Blenrep01/01/21Blenrep is used to treat multiple myeloma and it requires pre-authorization. It is a specialty drug covered under the medical benefit.
BI671  New
Breztri Aerosphere01/01/21Breztri Aerosphere is used to treat Chronic Obstructive Pulmonary Disease (COPD) and it requires pre-authorization. It is covered under the pharmacy benefit.
BI673  New
Evrysdi01/01/21Evrysdi is used to treat spinal muscular atrophy (SMA) in patients 2 months of age or older and requires pre-authorization. It is covered under the pharmacy benefit.
BI674  New
Fintepla01/01/21Fintepla is used to treat seizures associated with Dravet syndrome (DS) in patients 2 years of age and older and requires pre-authorization. It is covered under the pharmacy benefit.
BI675  New
Jelmyto01/01/21Jelmyto is used to treat urothelial cancer and requires pre-authorization. It is a specialty drug covered under the medical benefit.
BI676  New
Monjuvi01/01/21Monjuvi is used to treat a type of lymphoma and it requires pre-authorization. It is a specialty drug covered under the medical benefit.
BI677  New
Mycapssa01/01/21Mycapssa is used to treat acromegaly patients who have responded to and tolerated treatment with injectable octreotide or lanreotide and requires pre-authorization. It is an oral specialty drug covered under the pharmacy benefit and must be obtained from a contracted specialty pharmacy.
BI678  New
Onureg01/01/21Onureg is used to treat acute myeloid leukemia and requires pre-authorization. It is covered under the pharmacy benefit as a specialty drug and must be obtained through a contracted specialty pharmacy.
BI679  New
Rukobia01/01/21Rukobia is used to treat human immunodeficiency virus type 1 in heavily treatment-experienced adults with multidrug-resistant HIV infection who are failing their current antiretroviral regimen and requires pre-authorization. It is covered under the pharmacy benefit.
BI680  New
Upneeq01/01/21Upneeq is used to treat acquired blepharoptosis in adults and requires pre-authorization. It is covered under the pharmacy benefit.
BI681  New
Zepzelca01/01/21Zepzelca is used to treat lung cancer and requires pre-authorization. It is a specialty medication covered under the medical benefit.
Coming Amendments

Medical Policy Number
 Medical Policy Name Effective Date of Change Description of Changes
BI184  P
Autism Spectrum Disorder Treatment03/01/21Electroconvulsive therapy (90870) is considered E/I for Autism Spectrum Disorder.
Transcranial Magnetic Stimulation03/01/21TMS requires failure or intolerance to adequate pharmacotherapy, psychotherapy and documentation by ordering physician for reasons for ECT to not be clinically appropriate for the member.
BI672  New
ECT03/01/21Electroconvulsive therapy (ECT—also known as electroshock therapy) involves giving electrical impulses to an anesthetized patient to intentionally induce seizures. This is most commonly used to treat severe and/or treatment resistant depression but may also be used for catatonia or certain acute exacerbations of schizophrenia or mania. More than 20 sessions in a treatment series are rarely medically necessary. It requires pre-authorization to ensure medical necessity.
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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