Medicare AdvantagePrior AuthHigh impact
Update to Medical Benefit Drug Coverage for Medical Mutual Medicare Advantage Plans
Medical Mutual of Ohio·Oncology, Hematology·Pharmacy
Effective date
Nov 1, 2023
We identified it
Jun 20, 2026
Summary
Effective November 1, 2023, Medical Mutual Medicare Advantage Plans will require prior authorization for Infugem (gemcitabine) and Pemfexy (pemetrexed) chemotherapy drugs. Other formulations of these same drugs will continue to be managed by claims edit without prior authorization requirements.
Action Required
Immediately: Billing team must update system to require prior authorization for HCPCS codes J9198 (Infugem) and J9304 (Pemfexy) for all Medical Mutual Medicare Advantage patients. Update encounter forms to alert providers that these specific drug brands require prior auth while other formulations (J9201, J9305, J9294, J9296, J9314, J9297) do not. Claims for J9198 and J9304 will be denied without prior authorization.