Medicare AdvantagePrior AuthMedium impact
Update to Medical Benefit Drug Coverage for Medical Mutual Medicare Advantage Plans
Medical Mutual of Ohio·Rheumatology, Gastroenterology, Dermatology·Pharmacy
Effective date
Jun 15, 2022
We identified it
Jun 20, 2026
Summary
Medical Mutual changed their preferred infliximab products for Medicare Advantage plans effective June 15, 2022. New patients must try preferred drugs (Inflectra or Remicade) before non-preferred drugs (Avsola or Renflexis) can be prescribed, requiring prior authorization for non-preferred options.
Action Required
Immediately: Billing team must update prior authorization workflows for Medical Mutual Medicare Advantage patients receiving infliximab therapy. Verify preferred drug status before billing - use Q5103 (Inflectra) or J1745 (Remicade) as first-line options. For Q5121 (Avsola) or Q5104 (Renflexis), obtain prior authorization through Medical Mutual's process, documenting medical necessity or previous step therapy completion. Update encounter forms to remind providers of step therapy requirements.