Medicare AdvantagePrior AuthMedium impact
Update to Medical Benefit Drug Coverage for Medical Mutual Medicare Advantage Plans - May 2021
Medical Mutual of Ohio·Oncology, Hematology·Pharmacy
Effective date
Aug 1, 2021
We identified it
Jun 20, 2026
Summary
Medical Mutual updated their preferred pegfilgrastim products list for Medicare Advantage plans effective August 1, 2021. New patients must try preferred drugs (Fulphila, Neulasta, Nyvepria, Udenyca, Ziextenzo) before non-preferred options can be prescribed, requiring step therapy compliance.
Action Required
By August 1, 2021: Billing team must update prior authorization processes to ensure step therapy requirements are met for pegfilgrastim products. Providers must document trial of preferred drugs (Fulphila Q5108, Neulasta J2505, Nyvepria Q5122, Udenyca Q5111, Ziextenzo Q5120) before prescribing non-preferred options. Follow Medical Mutual coverage determination process for exceptions. Claims may be denied without proper step therapy documentation.