All PlansPrior AuthHigh impact
Coming soon: Formulary updates effective Jan. 1, 2025
UPMC Health Plan·Oncology, Allergy & Immunology, Pharmacy·Pharmacy
Effective date
Jan 1, 2025
We identified it
Aug 7, 2026
Summary
UPMC Health Plan is implementing two major pharmacy policy changes effective January 1, 2025: (1) certain IVIG/SCIG products will shift from preferred to nonpreferred status across all lines of business, and (2) select medically administered IV oncology products will newly require prior authorization for new therapy starts. Prior authorization continues to be required for all IVIG/SCIG products regardless of preferred status.
Action Required
By December 31, 2024: (1) Billing team must review the preferred and nonpreferred IVIG/SCIG product lists at upmchp.us/PreferredImmuneGlobulins and update billing system formulary records to reflect status changes effective Jan 1, 2025. Ensure claims for nonpreferred products are flagged for potential member cost-sharing differences. (2) Obtain the complete list of IV oncology products requiring new prior authorization at upmchp.us/IVoncologyPA. Update billing software and provider order entry systems to require prior authorization ONLY for new patient starts (not existing therapy continuations) of these oncology products for all UPMC lines of business. (3) Configure system to submit PA requests through SureScripts ePA or the UPMC provider portal at upmchp.us/ProviderPharmacyPAForms. (4) Notify oncology and immunology providers and clinical staff of the new PA requirement and exemption for existing patients to prevent claim denials. (5) Verify that existing IVIG/SCIG authorizations do not require updates when members transition to preferred products in 2025. Failure to implement prior authorization for new-start IV oncology therapies will result in claim denials.