Medications Covered Under Medical Insurance Policy
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Defines medical necessity, prior authorization expectations, and general coverage criteria for medications administered by a medical professional when no more specific medical policy exists; applies to Baylor Scott & White Health Plan lines of business and related plan types.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medical necessity criteria
Covered when ALL of the following are met
from policy
from policy
from policy
captures InterQual, compendia, and trials pathways
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from policy
from policy
Medications that were approved under the FDA's accelerated approval pathway but for which the indication was subsequently withdrawn by the FDA are not considered medically necessary and are excluded from coverage.
Requests for drug use for indications that are not supported by recognized compendia or by sufficient clinical trial evidence may be considered unproven, experimental, and investigational and therefore not medically necessary. The policy requires either support in a standard drug reference compendium (for example AFHS‑DI, NCCN Drugs and Biologics Compendium, DrugDex, Clinical Pharmacology) or demonstration of safety and effectiveness by at least two well‑designed controlled clinical trials when relying on the evidence pathway.
Coding / Billing
| CPT Codes: | Not enumerated in policy; list may apply depending on medication and service |
| HCPCS Codes: | Not enumerated in policy; list may apply depending on medication and service |
| ICD10 codes: | Not enumerated in policy; inclusive list may not be presented |
| ICD10 Not covered: | Not enumerated |
Provider Actions & Authorization
Prior Authorization Required
Prior authorization is required for medications covered under this policy when the member’s plan or the drug’s coverage pathway indicates PA. Applicable InterQual® criteria will be used when available to evaluate requests that require prior authorization.
- Prior authorization requirement varies by line of business—see member EOC/SPD for specifics.
- For Medicare, follow applicable NCDs/LCDs when present; if none apply, use policy criteria and InterQual® where specified.
- InterQual® subsets that return a final recommendation of 'requires additional review' will be escalated to a clinical pharmacist and medical director.
Unproven Indications — Denial Risk
Requests for indications that are not supported by accepted drug compendia or by at least two well-designed clinical trials may be considered unproven and are at risk for denial.
- Standard drug reference compendia accepted include AHFS Drug Information, NCCN Drugs & Biologics Compendium, Thomson Micromedex DrugDex (Strength of Recommendation Class IIb or better and Strength of Efficacy Class IIa or better), and Clinical Pharmacology.
- If the requested use is not represented in these compendia or lacks adequate clinical trial evidence, the request may be denied as not medically necessary.
Required Documentation
Providers must supply the diagnosis and supporting documentation with the prior authorization request. Supporting documentation should include relevant clinical notes, diagnostic test results, and laboratory data demonstrating medical necessity.
- Provide the indication/diagnosis and relevant labs/tests in the request.
- Include clinical notes that document prior therapies, response, intolerance, or contraindications when applicable.
- For Medicaid members in Texas, confirm any additional documentation required per TMHP/TMPPM and Texas Mandate HB154.
Background
Many medications have specific FDA‑approved dosing parameters, including recommended initial and maximum dosages. Use outside those labeled regimens (off‑label or unlabeled use) may be considered medically necessary only when supported by recognized compendia or sufficient peer‑reviewed evidence. When a medication that requires prior authorization aligns with an applicable InterQual® subset, that subset should be used to assess medical necessity; InterQual recommendations that require additional review are escalated to a clinical pharmacist and medical director as part of the authorization process.
Definitions
Initial Therapy Criteria
Initial therapy
Initial coverage requirements when no specific policy exists
from policy
captures InterQual, compendia, and trials pathways
from policy
from policy
Continuation / Renewal Criteria
Continuation therapy
Continuation/renewal requirements
from policy
from policy
from policy
Step Therapy
| Step | Requirement | Reference / Notes |
|---|---|---|
| 1 | For non-preferred medications, member must have trial and failure of an adequate trial of all preferred drugs in the same class or documentation of clinically significant intolerance or contraindication. | See BSWHP step therapy policies 306 and 307 for specific step requirements and definitions; InterQual® criteria apply when prior authorization is required. |
| 2 | Provider must supply supporting documentation from the patient’s medical record, including the indicated diagnosis, applicable labs/tests, and specialist consultation as appropriate to demonstrate failure/intolerance and medical necessity. | Policy requires documentation per Med. Necessity criteria; see policy notes on required documentation and prior authorization processes. |
| 3 | If the medication requires prior authorization and an applicable InterQual® subset exists, the member must meet InterQual® criteria; InterQual® subsets with a final recommendation requiring additional review will be reviewed by a clinical pharmacist and medical director. | InterQual® applicability and review escalation referenced in policy; see policy history and InterQual® clarification. |
Site of Care
Confirm infusion‑site indication and per‑administration dosing
This policy provides indications and maximum dosage per administration for medications administered by a medical professional; when requesting medications given in an infusion or clinic setting, ensure the indication and dosing per administration align with the policy documentation.
- Site-specific rules and maximum per-administration doses are provided in this policy for medications administered by a medical professional.
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