MAB2026070104

By July 6, 2026: Billing and prior authorization teams must implement new clinical review guidelines for pharmacy prior authorization requests. (1) Update pharmacy staff and providers to include required documentation in prior auth requests: proof of partial-unit dosing necessity, inability to consolidate to higher strength, titration pack unavailability (if applicable), medical reasons for frequent dosing, or chart documentation showing lower doses failed. (2) Configure prior authorization submission workflows to require providers to attest to one of the five medical necessity criteria (1a-1e) listed in the policy. (3) Train clinical reviewers to apply the revised guidelines; requests not meeting criteria must be escalated to physician reviewers. (4) Update provider bulletins and enrollment communications to notify all MA fee-for-service pharmacies and prescribers of new documentation requirements. (5) Review current quantity limits/daily dose limits list at the provided URL and ensure billing systems reference the most current version. Failure to obtain prior authorization before dispensing drugs exceeding quantity limits will result in claim denials. Note: This policy applies to fee-for-service MA only; managed care members should direct questions to their respective MCO.