Nonformulary anti-infective prior authorization
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Policy governs prior authorization and coverage for nonformulary outpatient anti-infective agents (specific agents listed) under CareOregon; applies to medical benefit PA requirements and outpatient benefit nonformulary status.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Criteria
Covered when ALL of the following are met:
Approve for the requested duration if criteria met; do not approve if supporting evidence is not provided.
The agents listed in this policy are designated nonformulary for the outpatient benefit. This nonformulary status applies to outpatient coverage and will be applied when claims are adjudicated under the outpatient benefit.
Requests that do not include supporting evidence showing the requested anti-infective is medically appropriate and necessary will not be approved.
Coding
| No codes listed |
Provider Actions & Requirements
Prior authorization required; outpatient nonformulary
Prior authorization (PA) is required for the listed anti-infective agents when billed to the medical benefit. These agents are designated nonformulary for the outpatient benefit and will be subject to nonformulary status when requested in an outpatient setting.
Submit requests for agents without individual criteria
The plan adjudicates requests for any anti-infective that requires PA and does not have its own criteria under this umbrella policy; providers should submit requests under this policy when applicable.
Evidence of medical appropriateness required
Provide clinical evidence demonstrating that the requested anti-infective is medically appropriate and necessary; documentation sufficient to meet PA requirements on the medical benefit must accompany requests.
- Evidence must show the agent is either one of the listed included products or an anti-infective that requires PA and lacks its own criteria.
- If evidence supports medical appropriateness, approve for the requested duration per the policy language.
Denial risk if supporting evidence is insufficient
Requests lacking supporting evidence that the anti-infective is medically appropriate and necessary will not be approved; absence of required documentation creates risk of denial.
- Nonformulary outpatient requests or agents without individual criteria that do not include supporting evidence are subject to denial.
- Do not approve when evidence is not provided, per the policy criteria.
Background
This policy serves as an umbrella for multiple newer or specialized anti-infective agents that are nonformulary for outpatient use and require prior authorization (PA) on the medical benefit. Any anti-infective that requires PA and does not have its own criteria falls to this policy; the plan requires submitted evidence that the use is medically appropriate and necessary to approve therapy.
Definitions
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