Medical Benefit Drug Prior Authorization Program
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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.
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.
Coverage Criteria
General PA coverage criteria
Covered when ALL of the following are met
Refer to posted criteria for diagnosis, prescriber, dose, and prior medication trials
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.
Coding & Lookback Periods
Provider Actions & Submission Requirements
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)
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).
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.
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.
Definitions
Initial Therapy Criteria
Initial Therapy — Step therapy for new-to-therapy members
Step therapy for members new to therapy
See the program product lists for specific preferred and non-preferred products (e.g., pegfilgrastim, infliximab, rituximab, trastuzumab, filgrastim, epoetin, bevacizumab)
Refer to full Biosimilar Step Therapy Program Details for complete lists
Continuation / Existing Therapy Criteria
Continuation/Existing Therapy — Grandfathering and lookback
Grandfathering and lookback
Lookback windows are used to determine new-to-therapy status and grandfathering
Step Therapy Product 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
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.
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.
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.
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.
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.
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.
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.
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