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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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: 05/01/2020	Title: Padcev (enfortumab vendotin-ejfv)
Revision Date: 07/01/2020	Document: BI646:00
CPT Code(s): J9177
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) Padcev (enfortumab vedotin-ejfv) requires prior authorization. 2) Padcev is used to treat advanced urothelial cancer. 3) Padcev is a specialty drug covered under the medical benefit.
Medical Statement
Padcev (enfortumab vedotin-ejfv) is considered medically necessary for patients 18 years of age and older who meet the following criteria: 1) Diagnosis of locally advanced or metastatic urothelial carcinoma AND 2) Patient has previously received a platinum-containing chemotherapy regimen in the neoadjuvant/adjuvant, locally advanced, or metastatic setting AND 3) Patient has received a PD-1 inhibitor (e.g., Keytruda, Opdivo, Libtayo) or PD-L1 inhibitor (e.g., Tecentriq, Bavencio, Imfinzi).
Reference
1) Padcev Prescribing Information. Northbrook, IL; Astellas Pharma US, Inc.; December 2019. 2) NCCN Drugs & Biologics Compendium. Accessed online 3/16/20.
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.