Coverage Policies

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

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

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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.

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.

If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

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.


Effective Date: 07/01/2016 Title: Lonsurf (Trifluridine & Tipiracil)
Revision Date: Document: BI504:00
CPT Code(s):
Public Statement

Effective Date:

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)    Lonsurf (Trifluridine & Tipiracil) requires prior authorization.

2)    Lonsurf is used to treat colorectal cancer.

3)    Lonsurf is considered a specialty drug, covered under the pharmacy benefit, and must be obtained through a contracted specialty pharmacy.

Medical Statement

Lonsurf (Trifluridine & Tipiracil) is considered medically necessary for members meeting the following conditions:


1)    Diagnosis of metastatic colorectal cancer  AND

2)    Failure of a fluoropyrimidine, oxaliplatin, and irinotecan-containing regimen AND

3)    Failure of a bevacizumab containing regimen AND

4)    If RAS wild-type, failure of a Cetuximab or Panitumumab-containing regimen AND

5)    Absolute neutrophil count over1,500 per cubic millimeter (mm3) AND

6)    Platelet count over 75,000 per cubic millimeter (mm3) AND

7)    Contraceptive counseling has been provided AND

8)    If female and pre-menopausal, a negative pregnancy has been obtained.


As a specialty drug, it is limited to no more than a 30 day supply per fill.


1)    Aetna Specialty Pharmacy Clinical Policy Bulletin Antineoplastics @

2)    Lonsurf Prescribing Information. Taiho Oncology.  September 2015.

3)    Clinical Pharmacology. Accessed online 2/29/2016.

Application to Products

This policy applies to all health plans and products 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) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, 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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