Coverage Policies

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

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.

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 01/01/2018 Title: IL-23 Antagonists
Revision Date: 12/01/2020 Document: BI568:00
CPT Code(s): None
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)    IL-23 Antagonists, including Tremfya (Guselkumab) and Ilumya (tidrakizumab), require prior authorization.

2)    Tremfya and Ilumya are used to treat moderate to severe psoriasis.

3)    For the treatment of psoriasis with Tremfya, you must first try topical agents, phototherapy, and a non-biologic DMARD drug.

4)    Tremfya and Ilumya are covered under the pharmacy benefit as a specialty drug.


Medical Statement

Tremfya (Guselkumab) is considered medically necessary for adults aged 18 or older who meet the following criteria:

1)    Diagnosis of moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy AND

2)    Plaque psoriasis has been present for more than 1 year AND

3)    Ten percent or more body surface area is affected by plaque psoriasis or 5% with BSA if affecting body areas such as hands, feet, face, or genitals AND

4)    Member has a history or failure for at least a 3 month trial of, contraindication, or intolerance to ALL of the following:

a.    Topical therapy with corticosteroids, Vitamin D analogs (e.g. calcitriol, calcipotriene), calcineuring inhibitor (e.g. tacrolimus, pimecrolimus), or salicylic acid combination product; AND

b.    Phototherapy of at least 3 months duration with narrow-band UVB (in the office or at home) used alone or in combination with topical or systemic therapy; (See BI 029 for additional information regarding UV light therapy) This requirement may be waived in any of the following situations: a) history or presence of melanoma or other skin cancer, lupus erythematosus, or xeroderma pigmentosum, b) psoriasis involving areas around the eye where eye protection may cause blockage of phototherapy to affected area, c) documented systemic disease involving the joints (meeting the specific criteria for psoriatic arthritis), or d) very severe plaque thickness or scaling (4 on a scale of 0 to 4) AND

c.    Systemic therapy of at least 3 months duration with methotrexate or other non-biologic DMARD. This requirement may be waived in any of the following situations: a) member has chronic hepatic disease, b) member has acquired immunodeficiency syndrome (AIDS), c) member is pregnant or breast-feeding, or d) member has anemia, neutropenia, or thrombocytopenia.

5)    Ilumya is considered medically necessary only after adequate trial (minimum 3 months) of 3 of the following: (Humira, Cimzia, Stelara,Tremfya,or Skyrizi) AND

a)    Trial and failure of Taltz.

 

Tremfya is considered medically necessary for adults aged 18 or older who meet the following criteria:

1)    Diagnosis of moderately to severely active psoriatic arthritis (PsA) AND

2)    Have greater than 3 swollen and 3 tender joints AND

Inadequate response to at least one (1) non-biologic DMAR (e.g. methotrexate, cyclosporine, sulfasalazine, leflunomide) or has a contraindication to DMARDS.

Limits

As a specialty drug, Tremfya and Ilumya are limited to a maximum 30 day supply per fill.


Reference

1)    Tremfya Package Insert. Janssen Biotech, Inc.  July 2017.

2)    Clinical Pharmacology. Accessed online November 5, 2018.

3)    Ilumya Package Insert.  Sun Pharmaceutical Industries, Inc. March 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.