CurrentNeighborhood Health Plan of Rhode IslandPolicy Cmp_General_Pa_Without_Specific_Drug_Criteria_20250507.Medical 2

General Prior Authorization form for medically administered medications

Policy governs prior authorization and coverage criteria for medically administered medications under the medical benefit when no drug-specific criteria exist, applicable to Medicaid, Commercial, and Medicare members (subject to NCD/LCD).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyGeneral Prior Authorization form for medically administered medications

Policy CodePolicy Cmp_General_Pa_Without_Specific_Drug_Criteria_20250507.Medical 2

Change Typeclarified

Effective DateFeb 13, 2019

Next Review Date

Key ActionSubmit prior authorization with correct HCPCS code/units and all relevant documentation (lab values, treatment plan, chart notes) and demonstrate indication via compendia or peer-reviewed literature.

SourceLink

POLICY UPDATE CHANGES

Policy consolidates general prior authorization criteria for medically administered medications without drug-specific criteria.

6 monthsInitial coverage duration

6 monthsContinuation coverage duration

365 daysMedicare lookback for step therapy exemption

Coverage Summary

This policy establishes a uniform prior authorization (PA) process for medically administered medications that lack drug‑specific PA criteria. It covers medically administered drugs under the medical benefit for Medicaid, Commercial, and Medicare populations (subject to NCD/LCD), and the coverage stance is covered_with_criteria. The policy requires that medications be used for an FDA‑approved indication or a medically accepted indication as defined by specified compendia, that dosing follow FDA guidelines, and that required clinical documentation and correct HCPCS codes/units be submitted to support PA approval.

Coverage Durations and Medicare Step Therapy Exemption

Initial coverage duration6 months

Continuation coverage duration6 months

Medicare lookback for step therapy exemption365 days

Medicare prior exposure exemption windowmember previously received medication within past 365 days -> not subject to Step Therapy Requirements

Medical Necessity Criteria

Initial Therapy / Medically Necessary

Covered when ALL of the following are met:

ALL of the following

ONE of the following
- The medically administered medication is being used for an FDA approved indication or a medically accepted indication as defined in any one of the following standard reference compendia: AHFS-DI, Thomson Micromedex DrugDex, Clinical Pharmacology, Wolters Kluwer Lexi-Drugs, or peer-reviewed published medical literature indicating sufficient evidence exists to support use
- The medically administered medication is being dosed according to FDA guidelines
- The medically administered medication is being requested with the correct HCPCS code and units
- All relevant documentation (e.g., lab values, treatment plan, medical chart notes) is provided
  supporting clinical documentation required at time of prior authorization
- Patient must follow established clinical practice guidelines for treatment of their medical condition
- If requesting a reference product when a biosimilar product is available, the patient must have failure, intolerance or contraindication to the biosimilar product unless such therapies do not exist
- The patient has experienced an inadequate treatment response or intolerance to all first line agents, including the generic, if available
- Medicare members who have previously received this medication within the past 365 days are not subject to Step Therapy Requirements365 days
  applies only to Medicare members and only when member previously received same medication within past 365 days

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Continuation of Therapy / Renewal

Covered when ALL of the following are met:

ALL of the following

Patient meets all initial criteria
Patient is tolerating treatment and is not experiencing any unacceptable toxicity from the drug
Patient has disease stabilization or improvement in disease (as defined by established clinical practice guidelines)

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Investigational / Not Covered

ALL of the following

Therapies are considered investigational when used at a dose or for a condition other than those recognized as medically accepted indications per the specified compendia or peer-reviewed literature
Neighborhood does not provide coverage for drugs when used for investigational purposes

Provider Actions & Documentation

Prior Authorization

Prior authorization required for medically administered medications without drug-specific criteria

Submit a prior authorization request for medically administered medications that lack drug-specific criteria. Ensure the request uses the correct HCPCS code(s) and units and includes all relevant supporting documentation (e.g., lab values, treatment plan, chart notes). Use recognized compendia or peer-reviewed literature to demonstrate a medically accepted indication.

affected codes: HCPCS
supporting references: AHFS‑DI, Thomson Micromedex DrugDex, Clinical Pharmacology, Wolters Kluwer Lexi‑Drugs, or peer‑reviewed literature

Documentation Required

Documentation of dosing and indication

Provide documentation that the medication dosing follows FDA guidelines and that the indication is either FDA‑approved or supported by one of the specified standard compendia or peer‑reviewed medical literature.

Step Therapy

Biosimilar step requirement

If a biosimilar is available, the patient must have failure, intolerance, or a contraindication to the biosimilar before a reference (originator) product will be approved. Note: Medicare members who previously received the same medication within the past 365 days are exempt from step therapy requirements per the policy.

Denial Risk

Non-payment risk for use outside guidelines

Use of a medication outside the policy guidelines (e.g., not FDA‑approved or unsupported by the listed compendia/literature, incorrect dosing, or incorrect HCPCS coding/units) may result in non‑payment unless approved through the exception process.

Background

Purpose: To support safe, effective, and appropriate use of medically administered medications that do not have drug‑specific criteria. The policy relies on specified standard compendia and peer‑reviewed literature to define medically accepted indications (AHFS‑DI, Thomson Micromedex DrugDex, Clinical Pharmacology, Wolters Kluwer Lexi‑Drugs, or peer‑reviewed published medical literature). Dosing must align with FDA guidelines. The policy applies to Medicaid, Commercial, and Medicare members, with Medicare application subject to applicable NCD/LCD guidance per 42 CFR 422.101; use outside these guidelines may result in non‑payment unless an exception is approved.

Definitions: Medically accepted indication — an indication recognized in AHFS‑DI, Thomson Micromedex DrugDex, Clinical Pharmacology, Wolters Kluwer Lexi‑Drugs, or peer‑reviewed published medical literature.

Type	Name/Note	Number	Effective
NCD	Applies if present

Revision History

2019-02-13policy effective

Policy effective date for the General Prior Authorization form for medically administered medications.

2019-02-13review

Initial review date recorded.

2020-09-28review

Policy review.

2021-02-11review

Policy review.

2022-02-10review

Policy review.

2023-02-01review

Policy review.

2023-12-07review

Policy review.

2024-01-04review

Policy review.

2025-05-07last_reviewLatest

Review history shows multiple review dates through 05/07/2025; no clinical policy statement changes indicated.

OpenPayer

General Prior Authorization form for medically administered medications

Coverage Summary

Medical Necessity Criteria

Coding

Provider Actions & Documentation

Background

Medicare Determinations

Revision History