Summary of Program
The Medical Specialty Drug Programs promote the application of current scientific clinical evidence for certain Specialty Drugs.
Prior authorization is required for outpatient and office services only for the medical benefit specialty drugs impacted. Specialty drugs rendered in and appropriately billed with any of the following places of service do NOT require prior authorization: emergency room, observation unit, and urgent care center or during an inpatient stay.
The specialty drug prior authorization requirements apply to all participating physicians, health care professionals, facilities and ancillary providers ("Providers") that order or render certain specialty drugs.
Compliance with this process is required.
Failure to follow the Specialty Drug Prior Authorization process may result in a denial. Claims denied for failure to request prior authorization may not be billed to the Customer.
Failure to meet clinical criteria will result in a denial for lack of medical necessity or on drug policy criteria for proven indicators in accordance with the Customer's benefit document. Upon issuance of the denial, the Customer and Provider will receive a denial notice with the appeal process outlined.
There are some variations in the list of specialty drugs that require prior authorization between our Commercial benefit plans, our Medicare Advantage benefit plans and our Community plans.
For program specific information including the list of drugs, please reference the applicable benefit plan:
- Commercial Specialty Drug Prior Authorization Program
- Community Plan Specialty Drug Prior Authorization Program