Please share with your billing department or billing agency
We made updates to our medical policies for dates of service starting on March 1, 20241. These updates may affect your authorization requests and claims for the medications below that you buy and bill to us (medical benefit medications).
What you need to know
For the medications below, we’ve highlighted new steps to take when requesting authorization and submitting claims:
- Request authorization for the medication, just as you currently do.
- New: Include the dose and frequency of administration with your request.
Exception: Somatuline Depot (lanreotide) does not require prior authorization, but dosing limits will now apply to claims.
- We’ll review the authorization request.
- New: If the dose and frequency you requested is in line with our medical policy or FDA-approved dosing limits, we may approve the request. If the dose and frequency are over the limit, the authorization request will deny. If you disagree with the decision, you can always request an appeal.
- If the submitted claim matches what’s been approved, your claim will process.
- New: If it does not match what’s been approved, the claim will deny in its entirety.
- If the member had an existing authorization for the medication (prior to March 1), then the dosing and frequency edits will apply when a new authorization is requested.
Medications with dosing and frequency limits
| Name of medication | HCPCS code(s) | Medical policy |
|---|---|---|
| Actemra (Tocilizumab) | J3262 | Immune Modulating Drugs medical policy 004 |
| Avsola, Inflectra, Renflexis, Remicade | J1745, Q5103, Q5104, Q5121 | |
| Orencia (Abatacept) | J0129 | |
| Eylea (Aflibercept) | J0178 | Vascular Endothelial Growth Factor (VEGF) Inhibitors Step Therapy medical policy 092 |
| Prolia, Xgeva (Denosumab) | J0897 | Medical Utilization Management (MED UM) & Pharmacy Prior Authorization Policy 033 |
| Tepezza (Teprotumumab) | J3241 | |
| Soliris (Eculizumab) | J1300 | Soliris, Ultomiris, Myasthenia Gravis, and Neuromyelitis Optica Policy 093 |
| Lanreotide (Somatuline Depot) | J1930 | N/A |
| Xolair (Omalizumab) | J2357 |
Injectable Asthma
Medications policy 017
New: This policy update will now take effect for dates of service on and after July 1, 2024, not on March 1 as previously communicated. |
| Riabni, Ruxience, Rituxan, Truxima | J9312, Q5115, Q5119, Q5123 | Nononcologic Uses of Rituximab medical policy 123 |
| Entyvio (Vedolizumab) | J3380 | Entyvio (Vedolizumab) Policy 162 |
Resource
News Alert: Medication claim edits and medical policy updates delayed
Note: To access this News Alert, log in and go to News. Look for the News Alert from November 30, 2023 titled, Medication claim edits and medical policy updates delayed.
Questions
If you have any questions, please call Pharmacy Operations at 1-800-366-7778. As always, thank you for the care you provide to our members.
1. The Xolair (Omalizumab) policy changes will now be effective on July 1, 2024.
MPC_071823-2K-42