Prior authorization and specialty pharmacy medical step therapy requirements

Prior authorization updates

Effective for dates of service on and after May 1, 2024, the following medication codes billed on medical claims from current or new Clinical Criteria documents will require prior authorization.

Please note, inclusion of a national drug code on your medical claim is necessary for claims processing.

Visit the Clinical Criteria website to search for the specific Clinical Criteria listed below.

Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.

Step therapy updates

Effective for dates of service on and after May 1, 2024, the following specialty pharmacy code from current or new Clinical Criteria documents will be included in our existing specialty pharmacy medical step therapy review process. Step therapy review will apply upon prior authorization initiation or renewal in addition to the current medical necessity review of the drug noted below.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your local provider relationship management representative or call Provider Services at 800-450-8753.