Coverage Policies

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

High-Tech Imaging: High-Tech Imaging services are administered by National Imaging Associates, Inc. (NIA). 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.

If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

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: 12/01/2016 Title: Venclexta (Venetoclax)
Revision Date: 01/01/2020 Document: BI524:00
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)    Venclexta is used to treat a particular types of leukemia or lymphoma.

2)    Venclexta is an oral specialty drug covered under the pharmacy benefit.

3)    Venclexta (Venetoclax) requires prior authorization.

Medical Statement

Venclexta (Venetoclax) is considered medically necessary for patients meeting the following conditions:

1)    Patient is 18 years of age or older; AND

2)    Has a diagnosis of chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) and has received at least one prior therapy as a single agent or in combination with rituximab or obinutuzumab; OR

3)    Diagnosis of mantle cell lymphoma (MCL) and has received at least one prior therapy; OR

4)    Diagnosis of relapsed or refractory acute myeloid leukemia (AML); OR

5)    Newly-diagnosed with acute myeloid leukemia (AML)

a.  75 years or older or have comorbidities that preclude the use of intensive induction chemotherapy; AND

b.  Used in combination with azacitidine OR decitabine OR low-dose cytarabine AND for all diagnoses.

6)    Confirmation that patient has been assessed for tumor lysis syndrome risk and will receive appropriate prophylaxis as appropriate; AND

7)    If female, pregnancy and contraceptive counseling have been provided.


As specialty drug covered under the pharmacy benefit, Venclexta is limited to a maximum 30 day supply per fill.


1)    Venclexta Prescribing Information. Genentech USA, Inc. North Chicago, IL. April 2016.

2)    Clinical Pharmacology. Accessed online March 18, 2019.

3)    NCCN Drugs and Biologics Compendium. Accessed online 11-19-2019.

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.