Certain specialty medication precertification requests may require additional documentation

As part of our ongoing quality improvement efforts, we are updating our precertification processes for certain specialty medications. Effective August 2020, we may request additional documentation for impacted medications to determine medical necessity.  See the list of impacted medications in the attached PDF.

 

Upon request, providers shall submit documentation from the member’s medical record for each policy question flagged for documentation. A denial may result if documentation does not support medical necessity.

 

Should you have any questions, please refer to our Clinical Criteria policy website for specific medication criteria details, including documentation requirements.

1204-07210-PN-NE