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Provider Quick Alert

June 1, 2021
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
BI044  V
Tasigna07/01/21Additional covered diagnosis.
BI140  V
Nexavar07/01/21Additional covered diagnosis.
BI328  V
Zelboraf07/01/21Three additional covered diagnoses.
BI356  V
Jakafi07/01/21Updated age to 18 and older.
BI361  V
Inlyta07/01/21Additional covered diagnosis.
BI402  V
Cometriq or Cabometryx07/01/21Three additional covered diagnoses.
BI410  V
Pomalyst07/01/21Three additional covered diagnoses.
BI484  V
Ibrance07/01/21Additional covered diagnosis.
BI485  V
Lenvima07/01/21Additional covered diagnosis.
BI653  V
Tazverik07/01/21Additional covered diagnosis.
BI654  V
Ayvakit07/01/21Additional covered diagnosis.
BI686   New
Breyanzi07/01/21Breyanzi is indicated for the treatment of adult patients with relapsed or refractory large B-cell lymphoma (LBCL) after two or more lines of systemic therapy, including diffuse large B-cell lymphoma (DLBCL) not otherwise specified (including DLBCL arising from indolent lymphoma), high-grade B-cell lymphoma, primary mediastinal large B-cell lymphoma, and follicular lymphoma grade 3B. It is a specialty medication and it requires pre-authorization.
BI687   New
Viltepso07/01/21Viltepso is used to treat Duchenne Muscular Dystrophy. It is a specialty medication covered under the medical benefit and it requires pre-authorization.

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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