Site-of-service review and prior authorization criteria for selected IV/ injectable biologic and specialty drugs
Defines prior authorization, step therapy, and site-of-service medical necessity criteria for specific intravenous and injectable biologic drugs on one custom Open formulary (Formulary ID: 6062; Rx Plan F1) and applies to members of that plan and providers administering these agents.
Added coverage criteria for Abrilada (adalimumab-afzb) and multiple other adalimumab biosimilars and branded products.
Included age requirement for several indications across multiple adalimumab products (e.g., ankylosing spondylitis, PJIA, RA, PsA, Crohn's disease, UC, pyoderma gangrenosum, sarcoidosis).
Changed re-authorization duration of approval from 3 years to 12 months.
Updated preferred/non-preferred status for several biosimilars and branded products (e.g., Cyltezo from preferred to non-preferred; Yuflyma to preferred).
Added multiple HCPCS/HCPCS-like codes including Q5140–Q5145 and several J/Q codes for updated biologic entries.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.