CurrentUCarePolicy N/A

Medical Benefit Drug Prior Authorization Program

Defines UCare's 2023 medical benefit drug prior authorization requirements, workflows, and biosimilar step therapy preferences for providers submitting PA requests across all lines of business.

Policy Summary

PayerUCare

PolicyMedical Benefit Drug Prior Authorization Program

Policy CodePolicy N/A

Change TypeProgram continuation with material updates

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionSubmit prior authorization requests to Care Continuum via Express Path (online ePA), fax 1-877-266-1871, or phone 1-800-818-6747.

SourceLink

POLICY UPDATE CHANGES

A consolidated 2023 Medical Benefit Drug Prior Authorization program is continued with Care Continuum performing reviews for all lines of business.

A summary list noting that 218 drugs require authorization in 2023 and breakdown by therapeutic categories was provided.

A biosimilar preferred-product step therapy program and specific preferred/non-preferred product lists for multiple biologic categories were published.

218drugs requiring authorization in 2023

85oncology drugs requiring authorization

365 / 180lookback periods (Medicare / Medicaid & Exchange)

21biosimilar step drugs

Coverage Criteria

General PA coverage criteria

Covered when ALL of the following are met

Authorization requirements: Drug is on the 2023 medical drug prior authorization list and the provider submits a prior authorization request to Care Continuum using specified methods

Refer to posted criteria for diagnosis, prescriber, dose, and prior medication trials

Biosimilar step therapy: For applicable biologic categories, member is new to therapy and has trialed a preferred biosimilar/preferred product per the program before non-preferred/reference product is approved365/180-day lookback applies

Members with prior use within the lookback period are grandfathered

For authorization adjustments (such as end-date extensions), providers must contact Care Continuum using the established prior authorization submission methods. The original authorization must be active at the time of the request, and the provider must supply the reason for the extension and the revised end date. Adjustments are not approved to add an additional drug or when the patient is due for a renewal; those situations require a new review/renewal.

Policy Summary

PayerUCare

PolicyMedical Benefit Drug Prior Authorization Program

Policy CodePolicy N/A

Change TypeProgram continuation with material updates

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionSubmit prior authorization requests to Care Continuum via Express Path (online ePA), fax 1-877-266-1871, or phone 1-800-818-6747.

SourceLink

On This Page

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Provider Actions & Submission Requirements

Prior Authorization

Prior authorization required for listed medical drugs

Prior authorization is required for medical benefit drugs. Care Continuum performs UCare's Medical Benefit Drug prior authorization reviews for all lines of business. Providers must initiate prior authorization requests using one of the Care Continuum methods below; requests sent by other means or submitted post-service may be delayed or denied.

Online (ePA) via Express Path Portal: https://www.express-path.com/
Fax: authorization form to Care Continuum at 1-877-266-1871
Phone: Care Continuum at 1-800-818-6747
Grid of medical drugs requiring prior authorization, criteria, and prior authorization form posted at ucare.org/providers/pharmacy/ (Medical Injectable Drugs Prior Authorization Resources)

Step Therapy

Preferred product biosimilar step therapy

UCare requires a preferred-product (biosimilar) step before coverage of non‑preferred or reference biologic products for most listed categories. The step applies to members new to therapy only; members with a history of use of the reference product within the lookback window are grandfathered.

Step therapy applies to specified biosimilar/reference product groups (examples below).
Lookback windows: 365 days for Medicare; 180 days for Medicaid and Health Exchange.
Members with a prior history of use of the reference product during the applicable lookback period will be grandfathered (no step required).

Documentation Required

Authorization adjustment requirements

To request medical drug prior authorization changes (adjustments or extensions) or to initiate new requests, providers should contact Care Continuum using the methods above. Adjustments must be made while the authorization is active. End-date extensions are allowed for scheduling or clinical reasons (for example, delayed chemotherapy due to low blood counts) and require the reason for extension and the revised end date. Adjustments are not approved when an additional drug is requested or when the patient is due for a renewal — in those cases a new review/renewal is required.

Authorization must be active to request an adjustment.
Required information for an extension: reason for extension and revised end date.
Adjustments not permitted for requests for additional drug or routine renewals — submit a new review/renewal.

Denial Risk

Submission methods and timing

Post-service or retrospective pharmacy authorization requests, and requests for non‑participating providers, must be sent to UCare (not Care Continuum) using the contact methods below. Requests that do not follow the Care Continuum submission methods for standard prior authorization or that are sent post-service may face processing delays or denial.

Fax to UCare, Attn: Clinical Services at 612-884-2499 or 1-866-610-7215
Mail to UCare, Attn: Clinical Services, P.O. Box 52, Minneapolis, MN 55440-0052
Do not submit standard pre-service prior authorization requests to UCare; use Care Continuum methods (ePA, Care Continuum fax/phone) to avoid delays.

Background

This document is administrative in nature and describes UCare’s 2023 Medical Benefit Drug prior authorization program and utilization management processes for a broad set of medical benefit drugs, including biologics and oncology agents. Care Continuum will perform prior authorization review for all lines of business; prior authorization requests must be initiated through Care Continuum by online ePA via the Express Path portal, fax to 1-877-266-1871, or phone at 1-800-818-6747. The policy sets a comprehensive prior authorization requirement for a grid of medical injectable drugs (218 drugs in 2023) and implements a preferred-product biosimilar step therapy approach for many biologic categories, with defined lookback periods and grandfathering rules to determine new-to-therapy status and continuity of existing therapy.

Initial Therapy Criteria

Initial Therapy — Step therapy for new-to-therapy members

Step therapy for members new to therapy

New-to-therapy step: Member must trial a preferred biosimilar or preferred product first for applicable biologic categories prior to approval of the reference or non-preferred biosimilarDetermined by lookback period to establish new-to-therapy status

See the program product lists for specific preferred and non-preferred products (e.g., pegfilgrastim, infliximab, rituximab, trastuzumab, filgrastim, epoetin, bevacizumab)

Product lists and examples: Preferred and non-preferred products are specified by drug category (examples: pegfilgrastim preferred = Udenyca, Ziextenzo, Neulasta, Neulasta Onpro; non-preferred = Fulphila, Nyvepria, Fylnetra)

Refer to full Biosimilar Step Therapy Program Details for complete lists

Drug category	Preferred products (trial required for new-to-therapy members)	Non-preferred / reference products
Pegfilgrastim	Udenyca; Ziextenzo; Neulasta; Neulasta Onpro	Fulphila; Nyvepria; Fylnetra
Infliximab	Avsola; Inflectra	Remicade; Renflexis; infliximab authorized generic
Rituximab	Truxima; Ruxience	Rituxan; Riabni
Trastuzumab	Kanjinti; Trazimera	Herceptin; Ogivri; Ontruzant; Herzuma
Filgrastim	Zarxio	Neupogen; Granix; Nivestym; Releuko
Epoetin	Retacrit	Procrit; Epogen
Bevacizumab	Mvasi; Zirabev	Avastin; Alymsys

Biosimilar Preferred-Product Details

Step Therapy

Pegfilgrastim: trial preferred pegfilgrastim product first for new-to-therapy members

For pegfilgrastim, members new to therapy must trial a preferred pegfilgrastim product (Udenyca, Ziextenzo, Neulasta, Neulasta Onpro) before a non-preferred product (Fulphila, Nyvepria, Fylnetra) will be approved; lookback periods and grandfathering rules apply.

Preferred products: Udenyca, Ziextenzo, Neulasta, Neulasta Onpro.
Non-preferred products: Fulphila, Nyvepria, Fylnetra.
365-day lookback for Medicare; 180-day lookback for Medicaid and Health Exchange; members with use within the lookback are grandfathered.

Step Therapy

Infliximab: trial preferred infliximab product first for new-to-therapy members

For infliximab, members new to therapy must trial a preferred infliximab product (Avsola, Inflectra) before non-preferred products (Remicade, Renflexis, infliximab authorized generic) will be approved; lookback and grandfathering rules apply.

Preferred products: Avsola, Inflectra.
Non-preferred products: Remicade, Renflexis, infliximab authorized generic.
365-day lookback for Medicare; 180-day lookback for Medicaid and Health Exchange; prior use within the lookback period is grandfathered.

Step Therapy

Rituximab: trial preferred rituximab product first for new-to-therapy members

For rituximab, members new to therapy must trial a preferred rituximab product (Truxima, Ruxience) before non-preferred products (Rituxan, Riabni) will be approved; lookback and grandfathering rules apply.

Preferred products: Truxima, Ruxience.
Non-preferred products: Rituxan, Riabni.
365-day lookback for Medicare; 180-day lookback for Medicaid and Health Exchange; prior use within the lookback period is grandfathered.

Step Therapy

Trastuzumab: trial preferred trastuzumab product first for new-to-therapy members

For trastuzumab, members new to therapy must trial a preferred trastuzumab product (Kanjinti, Trazimera) before non-preferred products (Herceptin, Ogivri, Ontruzant, Herzuma) will be approved; lookback and grandfathering rules apply.

Preferred products: Kanjinti, Trazimera.
Non-preferred products: Herceptin, Ogivri, Ontruzant, Herzuma.
365-day lookback for Medicare; 180-day lookback for Medicaid and Health Exchange; prior use within the lookback period is grandfathered.

Step Therapy

Filgrastim: trial Zarxio first for new-to-therapy members

For filgrastim, new-to-therapy members must trial the preferred filgrastim product Zarxio before non-preferred products (Neupogen, Granix, Nivestym, Releuko) will be approved; lookback and grandfathering rules apply.

Preferred product: Zarxio.
Non-preferred products: Neupogen, Granix, Nivestym, Releuko.
365-day lookback for Medicare; 180-day lookback for Medicaid and Health Exchange; prior use within the lookback period is grandfathered.

Step Therapy

Epoetin: trial Retacrit first for new-to-therapy members

For epoetin, new-to-therapy members must trial the preferred epoetin product Retacrit before non-preferred products (Procrit, Epogen) will be approved; lookback and grandfathering rules apply.

Preferred product: Retacrit.
Non-preferred products: Procrit, Epogen.
365-day lookback for Medicare; 180-day lookback for Medicaid and Health Exchange; prior use within the lookback period is grandfathered.

Step Therapy

Bevacizumab: trial preferred bevacizumab product first for new-to-therapy members

For bevacizumab, members new to therapy must trial a preferred bevacizumab product (Mvasi, Zirabev) before non-preferred products (Avastin, Alymsys) will be approved; lookback and grandfathering rules apply.

Preferred products: Mvasi, Zirabev.
Non-preferred products: Avastin, Alymsys.
365-day lookback for Medicare; 180-day lookback for Medicaid and Health Exchange; prior use within the lookback period is grandfathered.

OpenPayer

Medical Benefit Drug Prior Authorization Program

Coverage Criteria

Coding & Lookback Periods

Provider Actions & Submission Requirements

Background

Definitions

Initial Therapy Criteria

Continuation / Existing Therapy Criteria

Step Therapy Product Lists

Biosimilar Preferred-Product Details