Medica Provider News: May 2026

REQUIREMENTS: 1. By July 1, 2026: Billing and administrative staff must transition all specialty drug prior authorization submissions from the current Medica fax process to Prime Therapeutics' online portal. Staff should complete the 60-minute training webinar (registration deadline: at least one week before selected session). Register for webinar at: June 9, 9-10 a.m. CST OR June 17, 12-1 p.m. CST. Contact Provider Service Center at 1-800-458-5512 for registration link. 2. By August 1, 2026: Update billing system workflows to automatically require prior authorization for the following preferred biosimilar products: - IV infliximab: J1745 (Avsola), J1746 (Renflexis) - IV ustekinumab: J3357 (Steqeyma), J3358 (Yesintek) Update encounter templates and claim submission protocols to flag these drugs for prior auth before processing. NOTE: Members currently using these products will have authorizations pre-entered through their plan year end; however, new prescriptions and plan year renewals require proactive prior auth submission. 3. Immediate: Ensure clinical staff understand that prior authorization requirements do NOT apply to Medicare Cost or Medicare Supplement members—only to Commercial, IFB, ASO, and Medicare Advantage populations. Implement plan-type verification at point of submission to prevent unnecessary delays. 4. Before July 1, 2026: Update provider communication materials and internal workflows to direct staff to Prime Therapeutics portal rather than faxing Medica. Consequences of inaction: Claims for specialty drugs submitted without proper prior authorization or through outdated processes will be denied, delaying member access to therapy and creating revenue cycle delays.