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.

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: 04/01/2019 Title: Aemcolo (rifamycin)
Revision Date: Document: BI603:00
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)    Aemcolo (rifamycin) requires prior authorization.

2)    Aemcolo is used to treat travelers’ diarrhea caused by noninvasive strains of Escherichia coli in adults.

3)    Aemcolo is covered under the pharmacy benefit.


Medical Statement

Aemcolo (rifamycin) is considered medically necessary for patients meeting ALL of the following conditions:

1)    Patient is 18 years of age or older AND

2)    Patient has a diagnosis of Travelers’ diarrhea (TD) AND

3)    Diarrhea is not accompanied by fever or bloody stool AND

4)    One of the following:

a.    Trial and failure to one of the following:

                                          i.    Azithromycin

                                        ii.    Ciprofloxacin

                                       iii.    Levofloxacin

                                       iv.    Ofloxacin

b.    Resistance, contraindication, or intolerance to all of the following antibiotics:

                                          i.    Azithromycin

                                        ii.    Ciprofloxacin

                                       iii.    Lefofloxacin

                                       iv.    Ofloxacin


Limits

1)    The recommended dosage is two (2) tablets twice daily for three (3) days.  Consequently, Aemcolo is limited to a maximum quantity of 12 tablets per 180 days.


Reference

1)    Aemcolo Prescribing Information. Cosmo Technologies, Ltd. San Diego, CA. November 2018.

2)    Riddly MS, Connor BA, Beeching NJ, et al. Guidelines for the prevention and treatment of travelers’ diarrhea: a graded expert panel report. J Travel Med. 2017;24(suppl 1):S63-S80.


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.