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.
No material clinical or coverage changes in this revision.
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
Required Provider Actions and Authorization
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 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.
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
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
Step Therapy Requirements
| Step | Requirement |
|---|---|
| 1 | Step therapy approval may be required for some drugs; review the specific medical drug policy prior to requesting authorization. |
Typical Site of Administration
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.
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