July 2020

July 2020

In addition to the summary of monthly changes below, please also review our monthly Bulletin for recent and upcoming changes to our medical and dental policies, and associated changes to pre-authorization requirements. The Medical Policy Manual includes a list of recent updates and archived policies.

Oxygen concentrators to require pre-authorization effective August 1, 2020

In our February 2020 and April 2020 newsletter issues, we notified you that oxygen concentrators used by Medicare Advantage members for more than 90 days will require pre-authorization. The effective date of this requirement has changed to August 1, 2020.

Pre-authorization for specialty medications

Effective July 1, 2020, HCPCS J9145 and Q5111 will be added to the specialty medication pre authorization lists for CHG Healthcare Services (group #70000004), IEC Group (group #70000000) and Alsco, Inc. (group #70000002) members. View the complete list of specialty medications that require pre authorization for these members on our Commercial Pre authorization List.

eviCore guidelines to be revised

Effective July 1, 2020, eviCore will revise its guidelines for several components of our Physical Medicine program.

Pain intervention guideline revisions

  • Epidural Steroid Injections: Non-indications SNRB and Non-indications ESI: (#200.5 and 200.6)
  • Sacroiliac Joint Procedures: Procedure Codes (#203.5)

Joint surgery guideline revisions

  • Shoulder Surgery: Arthroscopic and Open Procedures (#315.4)

Spine surgery guideline revisions

  • Lumbar Microdiscectomy: Procedure Codes (#606.5)

Redlined versions of these revisions are published on eviCore’s website.

Medication policy updates

Listed below is a summary of medication policy additions and changes. Links to all medication policies, medication lists and pre-authorization information for our members, including real-time deletions from our pre-authorization lists, are available on our website.

New medication policies effective July 1, 2020:

  • Ayvakit, avapritinib, dru624
  • Brukinsa, zanubrutinib, dru619
  • High-cost medications for erectile dysfunction (ED), dru626
  • Medications for pulmonary arterial hypertension (PAH), dru633
  • Oral calcitonin gene-related peptide (CGRP) antagonists and 5-hydroxytryptamine
    (5-HT) 1f agonists for Acute Migraine, dru635
  • Tazverik, tazemetostat, dru627
  • Non-Preferred Products with Available Biosimilars, dru620

    • Preferred products will not require pre-authorization (see below)
    • Coverage of non-preferred products will be limited and require documented intolerance or contraindication to all preferred product(s) (see below)

Revised medication policies effective July 1, 2020:

  • Cystic fibrosis transmembrane conductance regulator (CFTR) modulators, dru544
  • Esbriet, pirfenidone, dru368
  • High-Cost Epinephrine Autoinjectors (Auvi-Q), dru484
  • High-cost naloxone products, dru483
  • High-cost ophthalmic prostaglandin analogues, dru476
  • Immediate-release (IR) Opioid Medication Products for Pain, dru516
  • Lynparza, olaparib, dru389
  • Ofev, nintedanib, dru369
  • Non-preferred pegfilgrastim products, dru563

    • Adding Ziextenzo as a preferred pegfilgrastim product in addition to Udenyca
    • Preferred pegfilgrastim products must be ineffective, not tolerated or contraindicated before we will cover non preferred pegfilgrastim products

Archived medication policies effective July 1, 2020:

  • Diacomit, stiripentol, dru568
  • High-cost ophthalmic prostaglandin analogues, dru476
  • Juxtapid, lomitapide, dru302
  • Potassium Binders for Hyperkalemia (Veltassa, Lokelma), dru554
  • Rayaldee, calcifediol extended release, dru487

Biosimilar products

The available biosimilar products and their preferred or non-preferred status effective July 1, 2020, are as follows:






Avastin, MVASI



Rituxan, Truxima



Herceptin, Herzuma, Kanjinti, Ogivri, Ontruzant