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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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: 07/01/2017 Title: Kisqali (Ribociclib)
Revision Date: 04/01/2020 Document: BI538:00
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)    Kisqali (Ribociclib) requires prior authorization for coverage.

2)    Kisqali (Ribociclib) is used to treat invasive breast cancer.

3)    Kisqali is an oral specialty drug covered under the pharmacy benefit.


Medical Statement

Kisqali (Ribociclib) is considered medically necessary for members meeting the following criteria:

1)    Diagnosis of hormone receptor (HR)- positive, HER2-negative advanced or metastatic breast cancer AND

2)    Is used in combination with an aromatase inhibitor in pre/perimenopausal or postmenopausal women or fulvestrant in postmenopausal women AND

3)    Patient has ECOG score of 0-1.


Limits

As an oral specialty drug, Kisqali is limited to a maximum 30 day supply per fill.


Reference

1)    Kisqali Prescribing Information. January 2020

2)    Clinical Pharmacology. Accessed online 03/09/20.

3)    NCCN Drugs & Biologics Compendium. Accessed 03/09/20.


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.