CommercialPrior AuthHigh impact
Medical Policy and Coding Updates - November 2024
Premera Blue Cross·WA, AK · Oncology, Hematology, Endocrinology +5 more·Medical Policy
Effective date
Jan 3, 2025
We identified it
Jun 16, 2026
Summary
Premera updated medical necessity criteria for multiple drug policies effective January 3, 2025 and February 7, 2025, changing preferred/non-preferred drug tiers and adding new coverage criteria for several specialty medications including oncology drugs, biologics, and GnRH analogs.
Action Required
Before January 3, 2025: Update prior authorization protocols for affected medications including Dupixent (requiring blood eosinophil count ≥300 cells/mcL), Herceptin products (now requiring trial of preferred agents Kanjinti or Trazimera first), and IL-5 inhibitors (updated eosinophil thresholds and prescriber requirements). Review formulary preferences for infliximab products (Inflectra now first-line, Avsola second-line) and rituximab products (Ruxience now preferred). Update authorization duration for GnRH analogs to up to 12 months initial authorization. Claims may be denied without proper prior authorization and step therapy compliance.