Prior authorization updates for medications billed under the medical benefit

Effective for dates of service on or after April 1, 2025, the following specialty pharmacy codes 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 preapproval initiation or renewal in addition to the current medical necessity review of all drugs noted below.

The list of Clinical Criteria is publicly available on our provider website. Visit the Clinical Criteria website to search for specific Clinical Criteria.