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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsUCare Medical Injectable Prior Auth Policy Update …
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    CurrentUCarePolicy N/A

    Medical Injectable Drug Authorization List (coverage criteria)

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    List of medical injectable drugs typically administered in provider offices that require prior authorization or step therapy under UCare's medical benefit; applies to participating and non-participating providers submitting authorization requests.

    Policy Summary
    PayerUCare
    PolicyMedical Injectable Drug Authorization List (coverage criteria)
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Last ReviewJan 9, 2026
    Next Review DateN/A
    Key ActionSubmit authorization requests via OnePA portal, fax to Care Continuum (1-877-266-1871) or call Care Continuum (1-800-818-6747); non‑participating providers fax to UCare at 612-617-3948.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    ~300+drugs listed (HCPCS codes included)
    Multipleauthorization submission methods
    01/09/2026policy list last update

    Coverage Criteria Summary

    Per the Minnesota Health Care Programs (MHCP) fee schedule and UCare guidance, Fact Code 4 products — defined as products with “general price not covered” — may be considered excluded products under the UCare medical benefit. Providers should confirm Fact Code 4 status on the MHCP fee schedule before submitting claims or authorization requests, as status and coverage implications can change.

    Code Listings and Status

    Non-Participating Providers (partial list shown)HCPCS
    Q2055Abecma
    J9264Abraxane
    J3262Actemra
    J0801Acthar Gel
    J0791Adakveo
    Non-Participating Providers (continued)HCPCS
    J9382Bizengri
    J9037Blenrep
    J9039Blincyto
    J0567Brineura
    Non-Participating Providers (additional selections)HCPCS
    J9286Columvi
    J3247Cosentyx IV
    J0584Crysvita
    J9145Darzalex
    J9063Elahere
    J1745Infliximab / Remicade (J1745 listed)
    J9271Keytruda
    J9354Kadcyla
    J1427Viltepso
    J3399Zolgensma

    Required Provider Actions and Authorization

    Step Therapy

    Prior Authorization/Step Therapy Requirement

    The medical drugs on this list are typically administered in the provider's office and require prior authorization or step therapy approval before they can be dispensed or administered under the medical benefit. Providers should review the applicable medical drug policy for individual drug-specific step therapy requirements before submitting an authorization request.

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for the drugs listed on the Medical Injectable Drug Authorization List. Failure to obtain required prior authorization may result in claim denial or non-payment. Drugs not found on this list do not require authorization through the medical benefit.

    Note

    How to Submit Authorization Requests

    How to submit authorization requests: • Participating providers: Online (ePA) via the OnePA portal, fax the authorization request form to Care Continuum at 1-877-266-1871, or call Care Continuum at 1-800-818-6747. • Non-participating providers: Fax the authorization request form to UCare at 612-617-3948.

    • Participating providers: OnePA (ePA), Fax 1-877-266-1871, Call 1-800-818-6747
    • Non-participating providers: Fax 612-617-3948
    Denial Risk

    Authorization Requirement and Denial Risk

    Providers must obtain prior authorization (and complete any required step therapy) before administering or billing for drugs on this list. Authorization approval should be confirmed prior to service; otherwise payment may be denied.

    Policy Background

    This document is an administrative list of medical injectable drugs that are typically administered in provider settings and that commonly require prior authorization or step therapy under the UCare medical benefit. The list directs providers to review the applicable medical drug policy for clinical coverage details and to verify any Fact Code 4 exclusions via the MHCP fee schedule prior to submission.

    Definitions and Fact Codes

    Fact Code 4
    TermFact Code 4
    DefinitionProducts with 'general price not covered'.
    ImplicationMay be considered excluded products under the UCare medical benefit.
    ReferenceSubject to MHCP Fee Schedule; review fee schedule prior to submission.
    Fact Code 4 status explanation
    Status descriptionProducts with 'general price not covered' may be considered excluded under the UCare medical benefit.
    Administrative effectFact Code 4 status can change based on the MHCP Fee Schedule.

    Step Therapy Requirements

    StepRequirement
    1Step therapy approval may be required for some drugs; review the specific medical drug policy prior to requesting authorization.

    Typical Site of Administration

    Note

    Office administration — medical benefit

    These drugs are typically administered in the provider’s office and are managed under the medical benefit; ensure administration setting is documented on the authorization request.

    Policy Summary
    PayerUCare
    PolicyMedical Injectable Drug Authorization List (coverage criteria)
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Last ReviewJan 9, 2026
    Next Review DateN/A
    Key ActionSubmit authorization requests via OnePA portal, fax to Care Continuum (1-877-266-1871) or call Care Continuum (1-800-818-6747); non‑participating providers fax to UCare at 612-617-3948.
    SourceLink
    On This Page
    Coverage Criteria SummaryCode Listings and StatusRequired Provider Actions and AuthorizationPolicy BackgroundDefinitions and Fact CodesStep Therapy RequirementsTypical Site of Administration
    Provider actionReview the complete MHCP fee schedule prior to submitting claims or authorization requests.
    Fee schedule linkMHCP fee schedule: https://mn.gov/dhs/partners-and-providers/policies-procedures/minnesota-health-care-programs/provider/billing/fee-schedule/