MedicaidPrior AuthMedium impact
Provider Letter 2024-07: RE: Prior Authorization of Kepivance™ – Effective May 6, 2024
Oklahoma SoonerCare·OK · Oncology, Hematology·Prior Authorization
Effective date
May 6, 2024
We identified it
Jun 20, 2026
Summary
Oklahoma Medicaid (SoonerCare) now requires prior authorization for Kepivance (palifermin) effective May 6, 2024. Members currently on therapy will be approved for continuation, but new patients starting after April 15, 2024 need PA submission to avoid treatment disruption.
Action Required
By May 6, 2024: Billing team must implement prior authorization requirement for Kepivance (palifermin) for Oklahoma SoonerCare members. Use PA form PHARM-261 from OHCA pharmacy forms page. Submit all PA requests to Pharmacy Prior Authorization Unit via fax (not Medical Authorization Unit or provider portal). For patients who started treatment after April 15, 2024, submit PA immediately with dates of previous doses listed. Contact 800-522-0114 option 4 for questions. Claims will be denied without proper prior authorization.