Latest Alaska Medicaid prior authorization updates25

• Prior AuthClinical/Medical PolicyEff. 2025-07-01Requirement for Designated Behavioral Health (BH) and Substance Use Disorder (SUD) ServicesGoverns prior authorization and fiscal year limits for select 1115 behavioral health (BH) and substance use disorder (SUD) residential services provided to Alaska Medicaid beneficiaries beginning July 1, 2025. Affects providers submitting service authorizations to HMS Gainwell when services will exceed fiscal year limits.Alaska MedicaidPsychiatry/Behavioral HealthAll Alaska Medicaid updates
• Prior AuthClinical/Medical PolicyEff. 2024-07-26Beqvez (fidanacogene elaparvovec-dzkt) — Prior Authorization CriteriaPrior authorization criteria for the use of Beqvez (fidanacogene elaparvovec-dzkt) in adults with moderate-to-severe hemophilia B under Alaska Medicaid, including approval, denial, monitoring, quantity limits, and duration of approval.Alaska MedicaidHematology/OncologyAll Alaska Medicaid updates
• Prior AuthClinical/Medical PolicyEff. 2023-12-29Home Oxygen and Oxygen Equipment — Coverage, Authorization, and Equipment RulesCoverage, prior authorization, testing, and equipment rules for home oxygen therapy and oxygen equipment for Alaska Medicaid members, including initial and renewal criteria, service authorization timeframes, and equipment limitations.Alaska MedicaidDurable Medical Equipment (DME)All Alaska Medicaid updates
• Prior AuthClinical/Medical PolicyEff. 2023-09-27Home oxygen and oxygen equipment authorization and reimbursementDefines Alaska Medicaid requirements for authorization, documentation, dispensing, billing, and reimbursement of home oxygen systems and related equipment for beneficiaries, and addresses stakeholder concerns about prior authorization, CMN/electronic orders, portable systems, batteries, and capped rentals.Alaska MedicaidDurable Medical Equipment (DME)All Alaska Medicaid updates
• Prior AuthClinical/Medical PolicyEff. 2023-03-03Therapy prior authorization and habilitation coverage changesGovernance of prior authorization thresholds, coding, and treatment plan requirements for physical, occupational, and speech-language pathology services under Alaska Medicaid; affects providers furnishing therapy services to Alaska Medicaid members.Alaska MedicaidPhysical Medicine, Rehab & TherapiesAll Alaska Medicaid updates
• Prior AuthClinical/Medical PolicyEff. 2022-11-23Orthodontic Services — Coverage Criteria and Prior AuthorizationThis document governs coverage, prior authorization, eligibility, and reimbursement rules for orthodontic services (limited, interceptive, and comprehensive) for Alaska Medicaid and Denali KidCare recipients.Alaska MedicaidDental/Oral & MaxillofacialAll Alaska Medicaid updates
• Prior AuthReimbursement/Payment PolicyEff. 2022-09-07Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) DeviceDefines Alaska Medicaid coverage, coding, prior authorization, billing, and reimbursement rules for Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) devices — both scleral cover shells and scleral contact lenses — and who may bill for them under Alaska Medicaid.Alaska MedicaidGeneralAll Alaska Medicaid updates
• Prior AuthClinical/Medical PolicyEff. 2022-01-21Tzield (teplizumab) prior authorizationCriteria and authorization requirements for Alaska Medicaid coverage of Tzield (teplizumab) to delay onset of Stage 3 type 1 diabetes in patients meeting stage 2 criteria. Applies to providers requesting prior authorization for Alaska Medicaid members.Alaska MedicaidEndocrinologyAll Alaska Medicaid updates
• Prior AuthClinical/Medical PolicyEff. 2022-01-12Medical Justification Requirements for TravelDefines the documentation and submission requirements for non-emergency transportation requests for Alaska Medicaid members, including when telehealth must be considered and exceptions for certain prior-authorized or urgent situations. Affects providers arranging or requesting Medicaid-funded patient travel in Alaska.Alaska MedicaidEmergency & Medical TransportationAll Alaska Medicaid updates
• Prior AuthReimbursement/Payment PolicyEff. 2019-08-14Pharmacy Claims Management and Prior AuthorizationGoverns Alaska Medicaid pharmacy claims processing, prior authorization (PA), step therapy, coordination of benefits/third-party liability, POS claim submissions, and override procedures affecting pharmacies and prescribing providers billing Alaska Medical Assistance.Alaska MedicaidGeneralAll Alaska Medicaid updates
• Prior AuthClinical/Medical PolicyEff. 2018-02-01Prolia®, Xgeva® (denosumab) prior authorizationPrior authorization criteria for denosumab products Prolia and Xgeva covering indications, approval and denial conditions, quantity limits, and approval durations for Alaska Medicaid members.Alaska MedicaidEndocrinologyAll Alaska Medicaid updates
• Prior AuthReimbursement/Payment PolicyEff. 2016-09-07Alaska Medicaid Pharmacy - Naloxone: point-of-sale edits and prior authorizationDefines Alaska Medicaid pharmacy claims processing edits and prior authorization requirements for naloxone products, and pharmacist actions when multiple Narcan® Nasal Spray fills occur; applies to Alaska Medicaid-enrolled beneficiaries and dispensing pharmacists.Alaska MedicaidGeneralAll Alaska Medicaid updates
• Prior AuthReimbursement/Payment PolicyEff. 2012-03-14Opioid Therapeutic Duplication EditsThis document explains Alaska Medicaid's implementation of automated therapeutic duplication edits for opioid analgesics, describing which products/categories trigger denials, the 19-day look-back window, override/prior authorization options, and point-of-sale override codes. It affects Alaska Medicaid recipients, prescribers, and pharmacies.Alaska MedicaidGeneralAll Alaska Medicaid updates
• Prior AuthClinical/Medical PolicyEff. 2011-08-22Opioid Analgesic Quantity Limits (Pharmacy Point-of-Sale)Establishes maximum daily pharmacy point-of-sale quantity limits for opioid analgesics for Alaska Medicaid claims, with override and prior authorization processes for specific patient groups. Applies to prescribers, pharmacists, and pharmacy claims processing for Alaska Medicaid recipients.Alaska MedicaidPharmacy & Specialty DrugsAll Alaska Medicaid updates
• Prior AuthReimbursement/Payment PolicyEff. 2011-04-13Pharmacist-delivered tobacco cessation counseling and medication quantity limitsDefines Alaska Medicaid coverage changes removing prior authorization for specified tobacco cessation medications, setting six-month quantity limits, and establishing reimbursement and billing requirements for pharmacist-delivered tobacco cessation counseling when ordered by an eligible prescriber.Alaska MedicaidGeneralAll Alaska Medicaid updates
• Prior AuthClinical/Medical PolicyAduhelm (aducanumab-avwa) prior authorization - Coverage CriteriaThis document defines Alaska Medicaid prior authorization requirements, clinical criteria, and utilization limits for Aduhelm (aducanumab-avwa) infusions for treatment of Alzheimer's disease.Alaska MedicaidNeurology/NeurosurgeryAll Alaska Medicaid updates
• Prior AuthAdministrative/Operational PolicyAlaska Medicaid General Prior Authorization FormTemplate and instructions for submitting general prior authorization requests to Alaska Medicaid (Magellan Medicaid Administration) for drugs and related services; affects prescribers, pharmacies, and requestors submitting PA requests for Alaska Medicaid members.Alaska MedicaidGeneralAll Alaska Medicaid updates
• Prior AuthClinical/Medical PolicyBenlysta (belimumab) prior authorizationPrior authorization criteria for Benlysta (belimumab) for treatment of systemic lupus erythematosus and lupus nephritis for Alaska Medicaid members, including age, diagnosis, prescriber, therapy, and dosing constraints.Alaska MedicaidImmunology/RheumatologyAll Alaska Medicaid updates
• Prior AuthClinical/Medical PolicyBimzelx (bimekizumab) prior authorization — coverage criteria for plaque psoriasis, psoriatic arthritis, nr-axSpA, and ankylosing spondylitisDefines Alaska Medicaid prior authorization criteria, approval/denial rules, quantity limits, and required documentation for bimekizumab (Bimzelx) for indicated adult inflammatory conditions.Alaska MedicaidImmunology/RheumatologyAll Alaska Medicaid updates
• Prior AuthClinical/Medical PolicyBotulinum toxin (Botox) prior authorization — multiple indicationsForm and criteria governing prior authorization requests for botulinum toxin (Botox) for Alaska Medicaid members across multiple indications (e.g., chronic migraine, spasticity, hyperhidrosis, dystonias, bladder conditions). Affects prescribers, physician-administered drug billing, and pharmacy requests to Alaska Medicaid.Alaska MedicaidNeurology/NeurosurgeryAll Alaska Medicaid updates
• Prior AuthClinical/Medical PolicyBriumvi (ublituximab-xiiy) prior authorizationThis policy governs prior authorization for Briumvi (ublituximab-xiiy) for treatment of relapsing forms of multiple sclerosis for Alaska Medicaid enrollees and specifies approval, denial, duration, dosing, and precautions that affect prescribers and patients.Alaska MedicaidNeurology/NeurosurgeryAll Alaska Medicaid updates
• Prior AuthClinical/Medical PolicyCommon Non-Emergency Medical Travel Events — Coverage CriteriaRules and guidance for arranging non-emergency travel for Alaska Medicaid members for common medical services (therapy, chronic conditions, dental, behavioral health, etc.). Affects providers arranging travel and verifying prior authorization and treatment plan requirements.Alaska MedicaidPhysical Medicine, Rehab & TherapiesAll Alaska Medicaid updates
• Prior AuthAdministrative/Operational PolicyDental Service Authorization (SA) request form and submission processGoverns completion and submission of Alaska Medicaid Dental Service Authorization (SA) requests by dental providers to the Alaska Medicaid Fiscal Agent; affects dental providers requesting prior authorization for services for Alaska Medicaid recipients.Alaska MedicaidGeneralAll Alaska Medicaid updates
• Prior AuthClinical/Medical PolicyDirect Acting Antivirals for Hepatitis C (HCV) — Coverage CriteriaPrior authorization and quantity limit policy for FDA‑approved direct acting antiviral (DAA) medications for treatment of chronic hepatitis C virus (HCV) infection for Alaska Medicaid members, including approval criteria, authorized regimens, and renewal requirements.Alaska MedicaidGastroenterologyAll Alaska Medicaid updates
• Prior AuthReimbursement/Payment PolicyDsuvia and Spravato Conditions of PaymentThis document states Alaska Medicaid coverage and billing conditions for Dsuvia and Spravato, including required settings, prior authorization requirements, administration supervision, and billing channel restrictions for providers serving Alaska Medicaid members.Alaska MedicaidGeneralAll Alaska Medicaid updates