CommercialPrior AuthMedium impact
Update to Commercial and ACA Medical Benefit Product Coverage for Medical Mutual Plans
Medical Mutual of Ohio·Oncology, Hematology·Medical Policy
Effective date
Nov 1, 2023
We identified it
Jun 20, 2026
Summary
Starting November 1, 2023, Medical Mutual will require prior authorization for Infugem (gemcitabine) and Pemfexy (pemetrexed) under commercial and ACA plans. Other brands of these medications will continue to be managed by claims edits without prior authorization requirements.
Action Required
By November 1, 2023: Billing team must update prior authorization workflows to require pre-approval for Infugem (J9198) and Pemfexy (J9304) for all Medical Mutual commercial and ACA patients. Update encounter forms to flag these specific brand medications. Ensure staff verify patient has Medical Mutual coverage and obtain prior auth before administration to avoid claim denials.