Coverage Policies

Important! Please note:

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.

High-Tech Imaging: High-Tech Imaging services are administered by Evolent. For coverage information and authorizations, click here.

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.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

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: 07/01/2022	Title: Kimmtrak
Revision Date:	Document: BI702:00
CPT Code(s): C9095, J9274
Public Statement
a) This policy will apply to all services performed on or after the above revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. 1) Kimmtrak (tebentafusp) requires prior authorization. 2) Kimmtrak is indicated for the treatment of HLA-A*02:01-positive adult patients with unresectable or metastatic uveal melanoma.
Medical Statement
Initial Approval Criteria A. Uveal Melanoma (must meet all): 1. Diagnosis of unresectable or metastatic uveal melanoma; 2. Prescribed by or in consultation with an oncologist; 3. Age ≥ 18 years; 4. Disease is HLA-A02:01-positive; 5. Request meets one of the following (a or b): a. Dose does not exceed 20 mcg (1 vial) on Day 1, 30 mcg (1 vial) on Day 8, 68 mcg (1 vial) on Day 15, and 68 mcg (1 vial) weekly thereafter; b. Dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence). Prescribed regimen must be FDA-approved or recommended by NCCN Approval duration: 6 months* Continued Therapy A. Uveal Melanoma (must meet all 1. Currently receiving medication via Centene benefit, or documentation supports that member is currently receiving Kimmtrak for a covered indication and has received this medication for at least 30 days; 2. Member is responding positively to therapy; 3. If request is for a dose increase, request meets one of the following (a or b):* a. New dose does not exceed 68 mcg (1 vial) weekly; b. New dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence). Prescribed regimen must be FDA-approved or recommended by NCCN Approval duration: 12 months* Codes Used In This BI: C9095 – Inj, tebentafusp-tebn, 1mcg (Code deleted & replaced by J9274 eff 10-1-22) J9274 - Inj, tebentafusp-tebn, 1 mcg
Reference
1. Kimmtrak Prescribing Information. Conshohocken, PA: Immunocore Commercial Limited; January 2022. Available at: https://www.kimmtrak.com/. Accessed February 16, 2022. 2. Clinical Pharmacology [database online]. Tampa, FL: Gold Standard, Inc.; 2022. Available at: http://www.clinicalpharmacology-ip.com/. Accessed February 16, 2022. 3. National Comprehensive Cancer Network. Melanoma: Uveal Version 2.2021 Available at: https://www.nccn.org/professionals/physician_gls/pdf/uveal.pdf. Accessed February 10, 2022. Addendum: 1) Effective 10-01-2022 – Code C9095 deleted and replaced by J9274.
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.

This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.