Catholic Health Initiatives (CHI) Members
QualChoice Members
| These services require Pre-Authorization. | Click to View Medical Policy | J-Codes |
| Actemra (Tocilizumab) |
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J3262
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| Acthar |
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J0800
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| Actimmune |
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J1830, J9216
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| Adagen |
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J2504
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| Adakveo |
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J0791
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| Adcetris |
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J9042
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| Adcirca |
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| Adempas |
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| Advate |
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J7192
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| Adynovate (Pegylated Antihemophilic Factor) |
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J7207
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| Aimovig |
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| Aldurazyme |
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J1931
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| Alecensa (Alectinib) |
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| Alferon N |
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J9215
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| Aliqopa |
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J9057
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| Alpha 1 - Antitrypsin Inhibitor Therapy |
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| Alphanate |
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J7186
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| AlphaNine SD |
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J7193
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| Alprostadil |
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J0270
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| Alunbrig (Brigatinib) |
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| Amitiza |
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| Ampyra |
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| Androgel 1.62% (Testosterone Gel) |
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| Antihemohilic Factor, Generic |
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J7182
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| Aralast |
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J0256
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| Asparlas |
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J9118
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| Astagraf XL |
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| Aubagio |
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| Avastin |
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J9035
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| Axiron |
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| Azelex Cream |
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| Bavencio (Avelumab) |
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| Bebulin VH |
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J7194
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| Beleodaq |
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| Benefix |
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J7195
|
| Benicar/Benicar HCT |
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| Benlysta (Belimumab) |
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J0490
|
| Bivigam |
|
J1599
|
| Blincyto |
|
C9449
|
| Boniva |
|
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| Botox (Inj.: Botulinum Toxin Type A, per unit) |
|
J0585
|
| Braftovi |
|
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| Carimune NF |
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J1566
|
| Caverject |
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J0270
|
| Ceredase |
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J0205
|
| Cerezyme |
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J1785
|
| Chantix (Varenicline) |
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| Cialis |
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| Cimzia |
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J0718
|
| Cladribine |
|
J9065
|
| Coagadex (Coagulation Factor X (Human)) |
|
J7175
|
| Corifact |
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J7180
|
| Cresemba |
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C9456
|
| crysvita |
|
J0584
|
| Cuvitru (Immune Globulin) |
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| Cyramza |
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C9025
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| Cystagon (Cysteamine) |
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| Cytogam (Cytomegalovirus Immune Globulin (CMV-IGIV)) |
|
J0850
|
| Darzalex (Daratumumab) |
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J9145
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| Daytrana |
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J0718
|
| Dextenza |
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C9048
|
| Diclofenac Gel 3% |
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| Differin Cream/Gel |
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| Diovan/Diovan HCT (Valsartan & Valsarta/HCTZ) |
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| Dysport |
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J0586
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| Edarbi/Edarbyclor (Azilsartan & Azilsatan/Chlorthalidone) |
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| Edex |
|
J0270
|
| Elaprase |
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J1743
|
| Elelyso |
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J3060
|
| Elzonris |
|
C9049
|
| Emcyt (Estramustine) |
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| Emgality |
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| Empliciti (Elotuzumab) |
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J9176
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| Enablex (Darifenacin) |
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| Enhertu |
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J9358
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| Entyvio |
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J3380
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| Epclusa (Sofosbuvir/Velpatasvir) |
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| Erbitux |
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J9055
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| Erwinaze |
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J9019
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| Esbriet (Pirfenidone) |
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| Eylea |
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J0178
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| Fabrazyme |
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J0180
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| Factor Products for Bleeding Disorders |
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| Farxiga |
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| Farydak |
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| Fentora |
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| Firazyr (Icatibant) |
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J1744
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| Flebogamma |
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J1567
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| Flolan |
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J1325
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| Flolan Diluent |
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S0155
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| Gammagard |
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J1566
|
| Gammaked |
|
J1561
|
| Gammaplex |
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J1557
|
| Gammaplex NOS |
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J1599
|
| Gamunex |
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J1561
|
| Gazyva |
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| Genotropin |
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J2941
|
| Gesterone |
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J2675
|
| Gestrin |
|
J2675
|
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QualChoice Network Medical Providers: You will receive verbal approval when requesting pre-authorization. Please inform your patient at that time that the request has been approved. Thank you.
Pre-authorization is the decision to cover a planned medical procedure, prescription drug or medical device. Pre-authorization is not a promise of payment for care or services.
Items with an asterisk (*) may be reviewed after the service has been performed. All others must be approved before services are performed. The member must get pre-authorization for any services outside the network noted on their ID card.
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.