Currentpriority healthPolicy N/A

Medical Drug Prior Authorization Criteria for physician-administered medications

Prior authorization criteria for physician-administered (infused/injected) medications covered under the medical benefit of Priority Health Choice Medicaid, Medicaid CSHCS, and Healthy MI plans in outpatient, non-emergent settings. Includes drug-specific initial and continuation criteria, prescriber requirements, age limits, dosing limits, approval timeframes, and links to billing policy requirements.

Policy Summary

Payerpriority health

PolicyMedical Drug Prior Authorization Criteria for physician-administered medications

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit the Medicaid Medical Authorization form and documentation that meets the drug-specific clinical criteria before administering physician-administered medications listed on the MDL.

POLICY UPDATE CHANGES

No material clinical or coverage changes were identified in this brief.

yesCovered with criteria

1 yrTypical initial auth

1 yrTypical continuation auth

200uDetrusor max per treatment

5Synagis max doses/season

Coverage Summary

Adakveo (crizanlizumab‑tmca) — J0791: Approved for sickle cell disease in patients age ≥16. Initial authorization: 6 months; continuation: 1 year. Initial PA requires confirmation of diagnosis, current weight, documentation of a 6‑month hydroxyurea trial or contraindication/intolerance, and at least two vaso‑occlusive crises in the prior year. Continuation requires weight and documentation of reduction in VOCs on therapy. Infusion‑site rules per billing policy 092 apply.

Adzynma (ADAMTS13, recombinant‑krhn) — J7171: Approved for congenital TTP (cTTP) in adults ≥18. Initial authorization: 6 months; continuation: 12 months. Initial PA requires genetic confirmation of cTTP, ADAMTS13 activity <10%, current weight, and prophylactic dosing not exceeding every 2 weeks. Continuation requires evidence of clinical benefit (reduction in TTP events, platelet improvement, decreased hemolysis).

Aldurazyme (laronidase) — J1931: Approved for MPS I (Hurler/Hurler‑Scheie/Scheie with moderate‑severe symptoms). Initial authorization: 6 months; continuation: 1 year. Initial PA requires confirmation of diagnosis and current weight. Continuation requires documentation of inability to receive home infusion (when applicable), weight, confirmation of diagnosis, and evidence of benefit or stabilization (e.g., FVC or 6MWT).

Alpha1‑antitrypsin augmentation products (Aralast/Aralast NP/Prolastin/Prolastin‑C/Zemaira/Glassia) — J0256/J0257: Approved for congenital AAT deficiency in adults ≥18 with clinically evident emphysema. Initial and continuation authorizations: 1 year. Initial criteria include documented emphysema, current weight, predicted FEV1 30–65%, nonsmoker status, and baseline AAT level <11 mmol/L (with conversion notes). Continuation requires ongoing documentation of emphysema, weight, FEV1 30–65%, nonsmoker status, pretreatment AAT <11 mmol/L, and current AAT >11 mmol/L. Billing policy 092 applies.

General Prior Authorization Process

General Prior Authorization Process — steps and responsibilities for requesting PA for physician‑administered drugs.

Policy Summary

Payerpriority health

PolicyMedical Drug Prior Authorization Criteria for physician-administered medications

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit the Medicaid Medical Authorization form and documentation that meets the drug-specific clinical criteria before administering physician-administered medications listed on the MDL.

On This Page

ALL of the following

Confirm whether the drug/HCPCS code requires prior authorization via the Medicaid Medical Drug List (MDL) and Priority Health's coverage documents.
Use the Medicaid Medical Authorization form to submit the PA request; include patient identifiers, diagnosis, prescriber specialty, and site of infusion if applicable.
Provide documented evidence required by the specific criteria group: diagnosis confirmation, relevant laboratory or genetic testing (e.g., ADAMTS13 activity, AAT level), current weight, prior therapy trials or contraindications, and baseline functional measures when requested.
For continuation requests, supply documentation of clinical benefit per the product’s continuation criteria (e.g., reduction in VOCs, decreased TTP events, stabilization or improvement in pulmonary function).
Observe product‑specific prescriber specialty and age limitations; when consultation is required, include documentation of specialist involvement.
Adhere to infusion‑site and billing rules (see billing policy 092). Providers are responsible for ensuring claims use the appropriate HCPCS code and that NDCs are billable per MDHHS policy.
Allow the stated approval timeframe to elapse for initial determinations (product specific); urgent/expedited reviews should follow Priority Health procedures and be clearly documented.

OpenPayer

Medical Drug Prior Authorization Criteria for physician-administered medications

Coverage Summary

Drug-specific Initial and Continuation Criteria

Not Covered / Experimental / Exclusions

Applicable Codes

Provider Actions & Required Documentation

Background

Clinical Evidence & Monitoring Metrics

Revision History