medical mutual - ohio medical drug Prior Auth update

Coverage Criteria and Product-Level Rules

inv-01: General coverage criteria

Prior authorization is required for listed drugs when used under the medical benefit; individual drug entries reference specific commercial and Medicare Advantage criteria codes or articles.

Global PA requirement: Prior authorization must be obtained for drugs listed in this document for both Commercial and Medicare Advantage enrollees unless an individual drug entry specifies otherwise.

See per‑drug criteria codes for clinical requirements (e.g., IC‑0598, IC‑0001, NCD references).

inv-02: Drug coverage metadata

Coverage and authorization are governed by the listed commercial criteria IDs and site-of-care indicators for each drug when present.

Per-drug coverage metadata: Each drug entry includes: HCPCS/J-code, Brand Name, Generic Name, Classification, Commercial Criteria reference (e.g., 201528), Commercial Site of Care flag (✓ if subject), Medication Sourcing start flags (e.g., (A,C,S)), and Medicare Advantage references.

Providers must consult the referenced commercial criteria document for detailed medical necessity requirements.

inv-03: Prior Authorization (inpatient and outpatient)

Coverage and authorization notes by product

PA for inpatient and outpatient: Prior Authorization required for inpatient and outpatient for specified gene/cell therapies and selected high‑cost products (examples: Q2055 Abecma, Q2058 Aucatzyl, Q2042 Kymriah, J3399 Zolgensma, C9399/J3590 entries noted as requiring PA for inpatient and outpatient).

See individual product entries for commercial criteria codes and Medicare NCD references.

inv-04: Medicare Advantage step therapy / NCD notes

Medicare Advantage step therapy and NCD references

Medicare step therapy/NCD: Certain products reference Medicare Part B Step Therapy Policy 201936 or National Coverage Determinations (NCDs) (examples: J9272 Jemperli, bevacizumab/Avastin products and related biosimilars, colony stimulating factors).

Follow the referenced Medicare Part B Step Therapy Policy 201936 or cited NCD when Medicare Advantage notes indicate it applies.

inv-05: Operational controls

Site-of-care and medication sourcing controls

Site of Care designation: Some products are marked with a Commercial Subject to Site of Care flag (✓) indicating site restrictions apply for administration (examples: J3262/Actemra, J0801/Acthar, J1290/Kalbitor, multiple J3590/C9399 entries).

When present, PA requests should identify and comply with the site‑of‑care designation.

Medication sourcing requirement: Multiple products list medication sourcing start indicators effective starting 1/1/2025 or other specified dates and may show codes such as (A),(C),(S); some entries also list later sourcing effective dates (examples: new sourcing effective 4/1/26, 7/1/26).

Providers must follow medication sourcing instructions (white‑bagging/ship‑to) per the product entry when placing orders.

inv-06: Per-drug commercial criteria

Coverage and PA applicability are determined per listed Commercial Criteria identifiers for each drug entry.

Per-drug commercial criteria: Each listed HCPCS/label is governed by the referenced Commercial Criteria ID (for example, J9203 governed by IC‑0320; J2941 governed by 95015; many J3590/C9399 entries reference numeric commercial criteria). Providers must meet the specific Commercial Criteria referenced for approval.

Reference the exact Commercial Criteria identifier shown in the product entry when submitting PA documentation.

inv-07: Product-level coverage linkage

Coverage entries list product-level commercial criteria IDs and site-of-care flags; decisions depend on matching the applicable commercial criteria referenced.

Product coverage mapping: Coverage and prior authorization decisions require adherence to the listed Commercial Criteria ID (e.g., Praluent = 201528; Privigen/Asceniv/Asceniv‑class immune globulins = IC‑0071) and any Medicare Advantage notes (e.g., LCD or Article references).

Include the Commercial Criteria ID on PA requests and supply supporting clinical documentation per that criteria.

inv-08: Product-level coverage links

Listed products are associated with internal commercial or Medicare Advantage criteria and may have site-of-care or sourcing rules

Product entry: Each drug entry includes code, brand/generic name, classification, commercial criteria reference, site‑of‑care flag (✓ when present), medication sourcing start dates (e.g., 1/1/2025 or later), and short operational notes (e.g., new PA effective dates).

For clinical medical‑necessity requirements, follow the referenced commercial or Medicare Advantage criteria document associated with the product.

inv-09: Code-specific coverage rules

Coverage/authorization stance is code-specific per listed commercial criteria identifiers or explicit notes

Per-code rule: For each listed HCPCS/CPT code, follow the referenced Commercial Criteria identifier (for example, CDP‑0549 governs J1823 Uplizna; IC‑0014 governs bevacizumab/Avastin biosimilars) or the explicit note shown (e.g., 'No PA required', 'PA required for inpatient and outpatient', 'Subject to Site of Care = ✓').

This section lists identifiers and operational flags; full clinical eligibility and required documentation are defined in the referenced criteria documents or Medicare references.

When a product listed in this document is identified as self‑administered in the Medicare Advantage notes (for example, entries where the notes state "Drug is self‑administered and is not covered under Part B. Drug may be covered under Part D."), coverage and prior authorization must follow the applicable prescription drug (Medicare Part D) pathway rather than the medical benefit. Providers should contact the member's pharmacy benefit manager using the number on the member ID card to confirm Part D prior approval requirements and routing. Prior authorization is still required for outpatient administration when the drug is billed under the medical benefit unless an individual drug entry specifies otherwise.

Bevacizumab products (Avastin and biosimilars) listed in this document require prior authorization when used for non‑ophthalmic indications only. Ophthalmic uses (e.g., intraocular/retinal injections) are explicitly excluded from the PA requirement — follow the per‑product entry and referenced Commercial or Medicare Advantage criteria for full details and applicable step therapy guidance.

Example: Several J3590/C9399 entries (and other listed products such as Praluent, Cosentyx, and somatropin) include Medicare Advantage notes indicating the drug is self‑administered and not covered under Part B; may be covered under Part D. In those cases, providers should bill and seek prior authorization under the pharmacy benefit (Part D) per the member's PBM requirements rather than the medical benefit.

Examples of self‑administered biologics and other products that are annotated as not covered under Part B and possibly covered under Part D include multiple brands shown under J3590 / C9399 mappings (e.g., Cosentyx SC, Kevzara, Skyrizi SC, and other J3590/C9399 entries). For such entries the Medicare Advantage note indicates the pharmacy benefit should be consulted for coverage and prior authorization.

Somatropin products (example: J2941 entries such as Zomacton) are flagged in Medicare Advantage notes as self‑administered and not covered under Part B; may be covered under Part D. When somatropin is self‑administered, providers should confirm benefit routing and obtain any required Part D authorizations through the PBM; if administered and billed under the medical benefit, follow the listed Commercial Criteria (e.g., 95015) and PA requirements.

Billing note: when a drug is identified as self‑administered and may be covered under Part D, do not submit medical benefit claims under Medicare Part B for that product; instead, confirm Part D coverage with the member's PBM and follow the PBM's prior authorization process. If the drug is being provided under the medical benefit (e.g., administered in a facility and billed to the plan), obtain the medical PA per the Commercial/Medicare Advantage criteria listed in this document.

Reminder: Avastin (bevacizumab) and bevacizumab biosimilars require prior authorization for non‑ophthalmic indications only. Ophthalmic uses are excluded from the PA requirement; follow the specific commercial criteria and Medicare Advantage notes for step therapy references and any effective dates that may apply.

As noted elsewhere in the document, prior authorization is required for bevacizumab products (Avastin) when used for non‑ophthalmic indications only. Providers should reference the listed Commercial Criteria and Medicare Advantage guidance for any step therapy or site‑of‑care requirements associated with these codes.

Additional reference: bevacizumab entries across multiple code mappings repeat that Avastin and its biosimilars require PA for non‑ophthalmic indications only. Ensure PA requests reference the correct HCPCS/Q‑code and the associated commercial/MA criteria shown in the product entry.

Codes, Systems, and Medication Sourcing Dates

Listed HCPCS/CPT codes and descriptionsHCPCS

Q2055	Abecma (idecabtagene vicleucel) — Oncology; Commercial Criteria = IC-0598, IC-0654-(E); Medicare Advantage Criteria = NCD: 110.24
J9264	Abraxane (paclitaxel protein bound particles) — Oncology; Commercial Criteria = IC-0001, IC-0360-(E)
Q5145	Abrilada (adalimumab-afzb) — Inflammatory conditions; Commercial Criteria = 200806
J3262	Actemra IV (tocilizumab) — Inflammatory conditions; Commercial Criteria = IC-0002
J3590	Actemra SC / multiple other products (tocilizumab and others) — various classifications; see individual entries for criteria codes
J0801	Acthar Gel (corticotropin) — Adrenocorticotropin stimulating hormone; Commercial Criteria = 201010-MRx
J0791	Adakveo (crizanlizumab-tmca) — Rare disease; Commercial Criteria = 202003
J9029	Adstiladrin (nadofaragene firadenovec-vncg) — Oncology; Commercial Criteria = IC-0691, IC-0745-(E)
J7171	Adzynma (ADAMTS13, recombinant-krhn) — Rare disease; Commercial Criteria = IC-0736
Q5150	Ahzantive (aflibercept-mrbb) — Ophthalmic; Commercial Criteria = 201513-EY

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Sample listed HCPCS/J-codes (partial)HCPCS

J2277	Aralast NP (alpha-1-proteinase inhibitor)
J0256	alpha-1-proteinase inhibitor (Aralast NP)
J0881	darbepoetin alfa (Aranesp)
J2793	rilonacept (Arcalyst)
J9261	nelarabine (Arranon)

Continued HCPCS/J/Q/A codes from excerpt (partial)HCPCS

J1554	intravenous immune globulin (Asceniv)
J9118	calaspargase pegol-mknl (Asparlas)
Q2058	Obecabtagene autoleucel (Aucatzyl)
Q5161	denosumab-kyqq (Aukelso)
J9035	bevacizumab (Avastin)
J3590	tividenofusp alfa-eknm (Avlayah) / other J3590 entries
J3145	Testosterone undecanoate (Aveed)
J9184	gemcitabine hydrochloride (Avgemsi)
J1826	interferon beta-1a (Avonex)
Q5121	infliximab-axxq (Avsola)

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Mixed HCPCS/J and category codes (partial)mixed

J3247	listed with subject to site of care and medication sourcing notes
C9399	used with brand/generic identifiers (e.g., Cosentyx SC / secukinumab)
J3590	generic placeholder used with multiple brand/generic entries (e.g., dupilumab)

Selected individual HCPCS/Q/J codes from excerptHCPCS

Q5143	Cyltezo (adalimumab - adbm)
J9308	Cyramza (ramucirumab)
Q5108	Fulphila (pegfilgrastim-jmdb)

Listed HCPCS codes (sample)HCPCS

J1744

Firazyr; icatibant; Hereditary angioedema

Listed HCPCS codes (sample)HCPCS

J9331

Fyarro; sirolimus albumin-bound nanoparticles; Oncology

Listed HCPCS codes (sample)HCPCS

J2941

Genotropin / Humatrope; somatropin; Growth hormone

Listed HCPCS codes (sample)HCPCS

J0599

Haegarda; c-1 esterase inhibitor (human); Hereditary angioedema

Listed HCPCS/J-codes and descriptionsHCPCS

C9309	listed with Commercial Criteria = 231205; Classification = CNS: Rare Disease
J9207	Ixempra / ixabepilone — Oncology
J2782	Izervay / avacincaptad pegol — Ophthalmic injections
J9281	Jelmyto / mitomycin — Oncology
J9272	Jemperli / dostarlimab-gxly — Oncology
J9043	Jevtana / cabazitaxel — Oncology
Q5160	Jobevne / bevacizumab-nwgd — Inflammatory conditions
J3590	Used for multiple brands (e.g., denosumab-desu, Kesimpta, Kevzara, anakinra, and many C9399 cross-listings)
C9399	Used with J3590 for multiple gene/rare-disease products (e.g., Kebilidi, Kresladi)
J2840	Kanuma / sebelipase alfa — Enzyme replacement therapy

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Covered HCPCS codes (sample from excerpt)HCPCSCovered

J9203

Mylotarg (gemtuzumab ozogamicin) — Oncology; Commercial Criteria = IC-0320, IC-0491-(E)

Growth hormone codesHCPCSCovered

J2941

Norditropin / Omnitrope / Nutropin AQ (somatropin) — Growth hormone; Commercial Criteria 95015

Immune globulinHCPCSCovered

J1568

Octagam (intravenous immune globulin) — IC-0071

OncologyHCPCSCovered

J9299

Opdivo IV (nivolumab) — Oncology; Commercial Criteria IC-0226, IC-0541-(E)

Additional biologics and injectablesHCPCSCovered

J1459	Privigen (intravenous immune globulin) — IC-0071
J0885	Procrit (epoetin alfa) — Erythropoiesis stimulating agents; Commercial Criteria 201832

Listed HCPCS codes in segmentHCPCS

J3590	Praluent / alirocumab referenced under J3590,C9399 in this section
C9399	Used alongside J3590 for multiple self‑administered biologics (e.g., Praluent, Repatha)
J1459	Privigen (intravenous immune globulin)
J1459	intravenous immune globulin (Privigen) -- classification and criteria referenced

Additional HCPCS/G-codesHCPCS | G-code

J2326	Spinraza (nusinersen)
J0013	Spravato (esketamine) and G2082, G2083 variants

Selected HCPCS/J-codes (partial list)HCPCS

J1299	Soliris; eculizumab; Rare disease; Commercial Criteria = 201421
J1930	Somatuline Depot; lanreotide; Oncology, Endocrine; Commercial Criteria = IC-0115
J1747	Spevigo IV/SC; spesolimab; Inflammatory conditions; Commercial Criteria = IC-P0674 / 250402

Covered HCPCS/J and miscellaneous codes listed in this partHCPCSCovered

J2326	Spinraza; nusinersen; CNS: Rare diseases; Commercial Criteria = 201705
J0013	Spravato; esketamine; Psychotherapeutic; Commercial Criteria = 201911 - MRx
J3590 C9399	Starjemza; ustekinumab-hmny; Inflammatory conditions; Commercial Criteria = 201012-2 / 201012
J3358	Stelara IV; ustekinumab; Inflammatory conditions; Commercial Criteria = 201012-2
J3357	Stelara SC; ustekinumab; Inflammatory conditions; Commercial Criteria = 201012
Q5099	Steqeyma IV/SC; ustekinumab-stba; Inflammatory conditions; Commercial Criteria = 201012-2 / 201012
Q5127	Stimufend; pegfilgrastim-fpgk; Colony stimulating factors; Commercial Criteria = 201827
J7321	Supartz; hyaluronan derivative; Viscosupplementation; Commercial Criteria = 99002
J2779	Susvimo; ranibizumab; Ophthalmic injections; Commercial Criteria = IC-0634
J2781	Syfovre; pegcetacoplan; Ophthalmic injections; Commercial Criteria = IC-0697

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Covered HCPCS (entries listed)HCPCS

J1823

Uplizna (inebilizumab-cdon) — Hematology: NMOSD; Commercial Criteria = CDP-0549

Covered HCPCS (entries listed)HCPCS

J9217

Vabrinty (leuprolide acetate depot) — Oncology; Commercial Criteria = 221201

Listed HCPCS/Codes and descriptionsmixed

J2777	Vabysmo (faricimab-svoa) — Ophthalmic injections; Criteria = IC-0659
J9303	Vectibix (panitumumab) — Oncology; Criteria = IC-0136, IC-0389-(E)
Q5129	Vegzelma (bevacizumab-adcd) — Oncology; Criteria = IC-0014, MMO-0450-(E)
J1325	Veletri (epoprostenol) — Pulmonary arterial; Criteria = 201806; Subject to Site of Care = ✓
Q4074	Ventavis (iloprost) — Pulmonary arterial hypertension; Criteria = 201807; Subject to Site of Care = ✓
J9376	Veopoz (pozelimab-bbfg) — Rare disease; Criteria = IC-0727
J1427	Viltepso (viltolarsen) — Rare disease; Criteria = IC-0562; Subject to Site of Care = ✓
J1322	Vimizim (elosulfase alfa) — Enzyme replacement therapy; Criteria = IC-0190; Subject to Site of Care = ✓
J7321	Visco-3 (hyaluronan or derivative) — Viscosupplementation; Criteria = 99002
J3396	Visudyne (verteporfin) — Ophthalmic injections; Criteria = IC-0181

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inv-41: Medication Sourcing start date — common start 1/1/2025 and other specific dates

Common medication sourcing start dateMany products: Medication Sourcing start date = 1/1/2025

Examples of later sourcing start datesEntries note additional new sourcing effective dates (examples: 2/1/26, 5/1/26)

Prior Authorization Process, Submission, and Operational Guidance

Prior Authorization

Prior Authorization Required

Prior Authorization Required. Medical Mutual requires prior authorization (PA) for the listed medical drugs for Commercial and Medicare Advantage members. Failure to obtain PA prior to administration may result in denial of coverage.

Applies to all new specialty drugs and new drugs with significant safety, clinical, or diversion concerns.
PA requirement applies to both inpatient and outpatient settings where noted in the drug listing.
For Medicare Advantage, Medical Mutual follows CMS guidance and applicable NCDs/LCDs; Medicare coverage is limited to clinically proven items and services.

Documentation Required

How to Submit Prior Authorization

How to submit prior authorization requests. Providers should submit PA requests to Medical Drug Management using the contact channels below; use the Prior Approval Form when available.

Site-of-Care Flags and Administration Location Guidance

Note

Medicare Part B Step Therapy Cross-References

Reference	Summary
Medicare Part B Step Therapy Policy 201936	Some drug entries in this document reference Medicare Part B Step Therapy Policy 201936; providers must follow the step therapy requirements in that policy where indicated in per‑product Medicare Advantage notes.
See per‑product Medicare Advantage notes	Multiple entries include a Medicare Advantage note directing: 'See Medicare Part B Step Therapy Policy 201936.' When present, Step Therapy Policy 201936 governs step therapy requirements for Medicare Advantage members.

Reference	Applicability
Medicare Part B Step Therapy Policy 201936	Referenced repeatedly in Medicare Advantage criteria notes; follow Policy 201936 for step therapy requirements affecting Medicare Advantage enrollees.
Examples of affected agents	Examples in the document referencing Policy 201936 include bevacizumab products (Avastin and biosimilars), selected colony stimulating factors, immune globulins, and multiple oncology agents; see individual code entries for specifics.

Reference	Effective date / Note
Medicare Part B Step Therapy Policy 201936	Some Medicare Advantage notes state a new Step Therapy requirement becomes effective 5/1/2026; when that date is shown in an entry, Step Therapy Policy 201936 requirements apply beginning 5/1/2026 for those agents.
Document examples	Multiple oncology and biologic entries include the note: 'New Medicare Advantage Step Therapy requirement effective 5/1/2026.' Providers should observe those effective dates in Medicare Advantage cases.

Reference	Example products
J9272 (Jemperli); bevacizumab products (Avastin and biosimilars); colony stimulating factors	Medicare Advantage notes on these products reference See Medicare Part B Step Therapy Policy 201936; follow that policy for step therapy requirements for these products as indicated.
Selected oncology agents (e.g., J9022 Tecentriq, J9299 Opdivo, J9380 Tecvayli)	These entries include Medicare Advantage references to Policy 201936 and some indicate new Step Therapy effective dates; follow Policy 201936 per the product note.

Reference	Instruction
See Medicare Part B Step Therapy Policy 201936	Where a product's Medicare Advantage notes state 'See Medicare Part B Step Therapy Policy 201936,' providers must follow that step therapy policy for Medicare Advantage members; consult the referenced policy for detailed step requirements.
Per‑product cross‑reference	Several immune globulin and biologic entries include this cross‑reference; the plan's Medicare Advantage step therapy handling is governed by Policy 201936 for those products.

Reference	Occurrences
Multiple product entries	The document contains multiple instances where product Medicare Advantage notes state 'See Medicare Part B Step Therapy Policy 201936.' These references appear across oncology, biologic, and immune globulin entries—follow Policy 201936 where cited.
Examples include:	Entries for J9321 (Epkinly), J9145 (Darzalex), J9272 (Jemperli), J9022 (Tecentriq), and various bevacizumab biosimilars include the Step Therapy 201936 reference.

Reference	Notes on effective dates and products
Medicare Part B Step Therapy Policy 201936 references	Document entries note new Medicare Advantage Step Therapy requirements becoming effective on various dates (notably 5/1/2026 for many entries); providers should check the per‑product Medicare Advantage note for the effective date and follow Policy 201936 accordingly.
Product examples with effective dates	Examples include multiple oncology agents and select biologics where the Medicare Advantage note includes 'New Medicare Advantage Step Therapy requirement effective 5/1/2026.'

Reference	Guidance
Follow Medicare Part B Step Therapy Policy 201936 when cited	Across the document, Medicare Advantage criteria or notes that reference Policy 201936 indicate that step therapy requirements in that policy govern Medicare Advantage members for the named products; providers must follow those step therapy requirements and the specified effective dates where present.
Provider action	When a product entry includes a Medicare Advantage note citing Step Therapy Policy 201936 (and any effective date), include adherence to that policy in the prior authorization submission for Medicare Advantage members.

Policy Background and Scope

Background: This document enumerates medical‑administered drugs that require prior authorization to ensure safe and effective use. It applies to drugs administered under the medical benefit for both Commercial and Medicare Advantage members and includes per‑product Commercial Criteria references, site‑of‑care flags, and medication sourcing start dates (many effective 1/1/2025 or later). Where Medicare Advantage notes indicate a product is self‑administered and not covered under Part B, the document also directs providers to the member's PBM for Part D prior authorization requirements.

Key Definitions and Operational Terms

inv-90: Investigational / Experimental definition

Investigational / Experimental definitionServices, procedures, therapies, devices and supplies not approved by governing bodies or that do not demonstrate comparable or superior outcomes to current practice standards as evidenced by peer-reviewed literature.

ScopeApplies to services lacking regulatory approval or sufficient peer-reviewed evidence to show effectiveness over current standards

Use in policyInvestigational/Experimental designation excludes coverage unless otherwise specified in product-specific criteria

inv-91: Medication Sourcing — operational designation and effective dates

Operational designation'Commercial Subject to Medication Sourcing Starting' denotes operational sourcing requirements for listed products with start dates (commonly 1/1/2025) and product-specific sourcing codes (A,C,S).

Policy Updates and Material Changes

2026-05-15document_effective_dateLatest

Policy effective date published as 2026-05-15; document lists multiple new PA and medication sourcing effective dates across 2025–2026.

2026-05-01medicare_advantage_step_therapy_addition

New Medicare Advantage step therapy requirement referenced (see Medicare Part B Step Therapy Policy 201936) effective 2026-05-01 for select agents.

2026-04-01

OpenPayer

Medical Drug Prior Authorization (Global PA) — Commercial & Medicare Advantage coverage criteria

Coverage Criteria and Product-Level Rules

Codes, Systems, and Medication Sourcing Dates

Prior Authorization Process, Submission, and Operational Guidance

Site-of-Care Flags and Administration Location Guidance

Medicare Part B Step Therapy Cross-References

Policy Background and Scope

Key Definitions and Operational Terms

Policy Updates and Material Changes