Specialty Pharmacy Precertification and Step Therapy list expansion

Effective for dates of service on or after April 1, 2025, the specialty Medicare Part B drug listed in the table below will be included in our precertification review process.

Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

Notification of Specialty Pharmacy Medical Step Therapy updates

Effective February 1, 2025, the following Part B medications from the current Clinical Criteria Guidelines will be included in our medical step therapy precertification review process. Step therapy review will apply upon precertification initiation, in addition to the current medical necessity review (as is current procedure). Step therapy will not apply for members who are actively receiving medications listed below.

Clinical UM Guidelines are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.