Coverage Policies

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Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

Use the index below to search for coverage information on specific medical conditions.

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Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

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QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:



Effective Date: 04/01/2008	Title: Continuity of Care: Prescription Drug Coverage
Revision Date:	Document: BI224:00
CPT Code(s):
Public Statement
1) No two formularies are the same. 2) QualChoice will make the following prescription drug accommodations for members of new groups: a) When a medication covered under a previous plan is not covered under the QualChoice plan, and that medication is one that is important to be taken every single day, QualChoice will accommodate with a one month refill allowed, and expect the member and his or her physician to arrange an alternate medication before the next refill is due. b) When a medication previously filled at a retail pharmacy now requires being filled at a specialty pharmacy, a one month refill will be allowed with the expectation that arrangements will be made with one of the QualChoice contracted specialty pharmacies before the next refill is due. c) When a medication previously refilled routinely requires adherence to a step-therapy protocol, if the pharmacist will identify to the pharmacy benefit manager who manages the QualChoice program that this is a medication that has been taken chronically by the member, it will be approved. d) When a medication requires preauthorization, QualChoice will waive that preauthorization process for ONE refill only to permit the member and his or her physician the time to comply with the process.
Medical Statement
1) When people change health plans, they often find that medications move to different member payment amounts than they were accustomed to, or that medications that were previously covered are no longer covered in the new plan. 2) QualChoice will make the following accommodations for members of new groups, to permit smooth transition between plans: a) When a medication covered under a previous plan is not covered under the QualChoice plan, and that medication is one that is important to be taken every single day, QualChoice will accommodate with a one month refill allowed, and expect the member and his or her physician to arrange an alternate medication before the next refill is due. b) When a medication previously filled at a retail pharmacy now requires being filled at a specialty pharmacy, a one month refill will be allowed with the expectation that arrangements will be made with one of the QualChoice contracted specialty pharmacies before the next refill is due. c) When a medication previously refilled routinely requires adherence to a step-therapy protocol, if the pharmacist will identify to the pharmacy benefit manager who manages the QualChoice program that this is a medication that has been taken chronically by the member, it will be approved. d) When a medication requires preauthorization, QualChoice will waive that preauthorization process for ONE refill only to permit the member and his or her physician the time to comply with the process. e) When a medication or its equivalent is available over the counter, the member will be expected to use the over-the-counter medication unless the prescription medication is on the QualChoice formulary. f) When a medication or its equivalent is available from QualChoice at a different tier from the previous coverage, the member will be responsible for the QualChoice member copayment. g) When a medication is one that is a plan exclusion (such as infertility medication, vitamins, nutritional supplements or cosmetic medication) no exception to the rule will be made (except in cases of extreme need – see a) above).
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

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