CommercialPrior AuthHigh impact
Medical Policy and Coding Updates - October 2024
Premera Blue Cross·WA · Oncology, Pulmonology, Allergy & Immunology +2 more·Medical Policy
Effective date
Jan 3, 2025
We identified it
Jun 16, 2026
Summary
Premera HMO is implementing significant prior authorization and coverage changes for multiple drug categories effective January 3, 2025, including new step therapy requirements for cancer drugs (HER2 inhibitors moving biosimilars to first-line), stricter criteria for asthma medications (IL-5 inhibitors requiring higher eosinophil counts), and new coverage criteria for multiple sclerosis treatments. These changes will require prior authorization documentation and affect billing for oncology, pulmonology, and neurology practices.
Action Required
By January 3, 2025: Billing team must update prior authorization requirements for Premera HMO patients receiving HER2 inhibitors (now requiring trial of biosimilars first), IL-5 inhibitors for asthma (new eosinophil count requirement >300 cells/mcL), alpha1-proteinase inhibitors, Dupixent, multiple sclerosis medications, and assisted reproduction drugs. Providers must update documentation templates to include new medical necessity criteria including specific lab values, previous medication trials, and specialist consultation requirements. Update encounter forms to remind providers of step therapy requirements. Claims will be denied without proper prior authorization and documentation.