Coverage Policies

High-Tech Imaging: High-Tech Imaging services are administered by Evolent. For coverage information and authorizations, 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.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

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: 06/01/2019 Title: Elzonris (tagraxofusperzs) Revision Date: 10/01/2019 Document: BI619:00 CPT Code(s): C9049, J9269 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)    Elzonris (tagraxofusp-erzs) requires prior authorization. 2)    Elzonris is used to treat a very rare condition known as blastic plasmacytoid dendritic cell neoplasm (BPDCN). Medical Statement Elzonris (tagraxofusp-erzs) is considered medically necessary for patients 2 years of age or older with a diagnosis of blastic plasmacytoid dendritic cell neoplasm (BPDCN). Codes Used In This BI: C9049    Elzonris J9269    Injection, tagraxofusp-erzs, 10mcg Reference 1)    Elzonris Package Insert. Stemline Therapeutics. December 2018. 2)    Clinical Pharamcology. Accessed online 04-25-2019. 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.