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.

For coverage information on high tech imaging (MRI, CT, PET) and nuclear medicine, administered by Evicore, 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.

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: 08/07/2013 Title: Mekinisit (Trametinib)
Revision Date: 10/01/2018 Document: BI421:00
CPT Code(s): 81210
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)    Mekinist (Trametinib) requires prior authorization.

2)    Mekinist (Trametinib) is used to treat melanoma, lung cancer, and thyroid cancer.

3)    Mekinist is a specialty drug and must be obtained through a contracted specialty pharmacy.

Medical Statement

For Melanoma:

Mekinist is considered medically necessary for patients who meet all the following criteria:

Diagnosis of unresectable or metastatic melanoma in patients with V600E or V600K mutation of the BRAF gene as detected by an FDA approved test (81210) as single-agent therapy OR

In combination with Tafinlar (dabrafenib) in a patient with a diagnosis of unresectable or metastatic melanoma in patients with BRAF V600E or V600K mutations, as detected by an FDA approved test (81210).


NOTE: Mekinist (trametinib) is not indicated in patients who have previously received therapy with a BRAF inhibitor (e.g. Zelboraf or Tafinlar)

For Non-Small Cell Lunc Cancer:

Diagnosis of non-small cell lunc cancer (NSCLC) with confirmed BRAF V600E mutation, as detected by FDA approved test in combination with Tafinlar (dabrafenib)


For Thyroid Cancer:

Diagnosis of locally advanced or metastatic anaplastic thyroid cancer (ATC) in patients with BRAF 600E mutation who have no satisfactory locoregional option, in combination with Tafinlar (dabrafenib).


Codes Used In This BI:


81210 – BRAF (v-raf murine sarcoma viral oncogene homolog B1), gene analysis, V600E variant.


1)    Mekinist Product Information.  GlaxoSmithKline.  May 2013

2)    Clinical Pharmacology.  Accessed online August 2018.

3)    NCCN Drugs and Biologics Compendium. Accessed online August 2018.

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.