We’re requiring prior authorization for some additional specialty drugs for MA PPO members

Additional specialty medications covered under the Medicare Part B medical benefit for Medicare Advantage PPO members will require prior authorization, beginning with dates of service on or after Feb. 12, 2018. These are medications that aren’t self-administered, but must be given by injection or infusion by a doctor or health care professional in the office setting.

The prior authorization requirement helps ensure that health care providers use the most effective therapies available, according to the Centers for Medicare & Medicaid Services coverage guidelines for medical necessity, safety and efficacy.

Doctors must obtain prior authorization and verify patient benefits to be eligible for payment for administering these services. Doctors can submit a request and obtain authorization within 90 days of the date of service. If prior authorization isn’t obtained, the claim will be denied.

Keep in mind that the patient must meet all the requirements and have the necessary coverage for the claim to be paid. Also, authorization isn’t a guarantee of payment. CMS benefit coverage rules and exclusions or limitations apply.

What specialty medications require prior authorization?
Listed below are the specialty drugs that have been added to the list for Medicare Part B prior authorization effective for dates of service on or after Feb. 12, 2018:

Our prior authorization program is evaluated on an ongoing basis, and we may add or remove drugs or procedures from our list of drugs that require prior authorization. When this happens, we’ll notify you through The Record or web-DENIS.

How do I initiate a prior authorization request?

See the July 2017 Record article for details.