PHARMACY / MEDICAL UTILIZATION MANAGEMENT GUIDELINE
Defines medical-necessity criteria for continuing coverage of maintenance medications when a member is new to the plan or when utilization management restrictions change for current members, distinguishing drugs with and without preferred generic/biosimilar alternatives and addressing manufacturer samples/coupons.
Clarified that the medications listed in this policy are subject to the product's FDA dosage and administration prescribing information.
Added coverage criteria for continuation of a maintenance medication for new to plan members for a drug that does have a preferred generic or biosimilar alternative (12/01/24).
Added coverage criteria for continuation of a maintenance medication for current plan members for a drug that does have a preferred generic or biosimilar alternative (12/01/24).