MAB2026063004

By July 6, 2026: Billing and clinical teams must implement the following: (1) Update prior authorization submission workflows to require documentation of specialist consultation (gastroenterologist, dermatologist, rheumatologist, ophthalmologist, immunologist, genetic specialist, pulmonologist, oncologist, etc.) for all Cytokine and CAM Antagonist prescriptions in the billing system; (2) Ensure prescribers document compliance with all nine medical necessity criteria outlined in Section I.B, including tuberculosis and hepatitis B screening results for applicable drugs, psychiatric history screening (suicide attempt, bipolar disorder, major depressive disorder) for drugs with behavioral/mood warnings, and disease severity classification; (3) For psoriasis cases, providers must document the specific potency and duration of topical corticosteroid trials attempted; (4) For Crohn's disease and ulcerative colitis cases, prescribers must document disease severity (moderate/severe) or the presence of high-risk/poor prognostic features per the guidelines; (5) For rheumatoid arthritis, document three-month trial failure of conventional non-biologic DMARD or documented contraindication/intolerance; (6) For juvenile idiopathic arthritis, document appropriate DMARD trial failure, systemic features, or disease severity risk factors; (7) Train billing staff to verify all required documentation before submission to PA MA program; (8) Update encounter forms and EMR templates to include checkboxes for specialist consultation, screening test dates, and disease severity assessment. Failure to obtain prior authorization or submit incomplete documentation will result in claim denials. Contact Fee-for-Service Provider Service Center at 1-800-537-8862 with questions.