Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

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

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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.

INDEX:



Effective Date: 10/01/2019	Title: Evenity (romosozumab-aggg)
Revision Date:	Document: BI625:00
CPT Code(s): J3111
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) Evenity (romosozumab-aqqg) requires prior authorization. 2) Evenity is used to treat osteoporosis in postmenopausal women at high risk for fracture. 3) Evenity is a specialty injection covered under the medical benefit.
Medical Statement
Evenity (romosozumab-aqqg) is considered medically necessary for patients meeting the following criteria: 1) Patient is 18 years of age or older AND 2) Patient is a postmenopausal female AND 3) Patient has a diagnosis of osteoporosis AND 4) Patient has not had a myocardial infarction or stroke within the past 12 months AND 5) Patient meets one of the following criteria: a. Prescribed by or in consultation with one of the following specialists: a gynecologist, endocrinologist, rheumatologist, geriatrician, orthopedist, or physiatrist; OR b. Failure of a 12-month trial of a bisphosphonate (alendronate is preferred) at up to maximally indicated doses, unless contraindicated or clinically significant adverse effects are experienced AND 6) Dose does not exceed 210mg per month AND 7) Patient has not received a total of 12 monthly doses. Codes Used In This BI: J3111 Injection, romosozumab-aqqg, 1mg
Limits
Evenity is limited to a maximum of 12 monthly doses in a lifetime per the FDA-approved labeling.
Reference
1) Evenity Prescribing Information. Thousand Oaks, CA. Amgen. April 2019. 2) Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists and American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis – 2016 – executive summary. Endocr Prac. 2016 Sep;22(9):1111-18.
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.

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