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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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.

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: 08/03/2011 Title: Dificid (Fidaxomicin)
Revision Date: 01/01/2019 Document: BI313:00
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)    Dificid (Fidaxomicin) requires prior authorization.

2)    Dificid is used to treat Clostridum Difficile-associated diarrhea (pseudomembranous colitis).


Medical Statement

Dificid is considered medically necessary for patients meeting the following criteria:

1)    Diagnosis of clostridium difficile-associated diarrhea.

2)    Documented trial/failure of or recurrence after at least one  course of vancomycin therapy in past 90 days.


Limits

Dificid is limited to 20 tablets per fill under the pharmacy benefit.


Reference

1)    Dificid Product Information.  Optimer Pharmaceuticals. 

2)    Louie TJ, Miler MA, Mullane KM, et al.  Fidaxomicin versus vancomycin for clostridium difficile infection. N Eng J Med 364(5);422-431. Feb2011

3)    Clostridium difficile Treatment Guidelines. Clinical Infectious Diseases, Volume 66, Issue 7, 19 March 2018, Pages e1-e48.


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.