MAB2026063004

By July 6, 2026: Billing and clinical teams must implement prior authorization procedures for ALL Cytokine and CAM Antagonist prescriptions in the PA MA program. SPECIFIC ACTIONS: (1) Update billing system to flag every prescription for these drug classes as requiring prior authorization before claims submission; (2) Ensure prescribers and pharmacists receive training on new clinical criteria including: specialist consultation requirements, tuberculosis (PPD or IGRA) and Hepatitis B (anti-HBs, HBsAg, anti-HBc) screening documentation, psychiatric history evaluation for Otezla and Siliq, and disease-specific severity/prognostic factor documentation for Crohn's disease, ulcerative colitis, rheumatoid arthritis, and JIA; (3) Create or update prior authorization request forms in system to require all nine verification elements (FDA approval, age-appropriateness, dose/duration, specialist consultation, contraindication check, concomitant drug justification, infection risk screening, behavioral risk screening, and disease-specific criteria); (4) Communicate policy changes to all prescribers and pharmacy partners in your network; (5) Establish workflow to verify prior authorization approval BEFORE dispensing or billing. CONSEQUENCES: Claims will be denied for Cytokine and CAM Antagonist prescriptions lacking complete prior authorization per updated guidelines. WHO: Billing team (system configuration), clinical/compliance team (provider training), and pharmacy liaison staff. WHERE: Update all prior authorization system rules, encounter forms, and internal policies.