Benefit Coverage Change for Medications

By September 15, 2026: Billing team must implement the following changes: (1) Update billing system rules to identify Signifor LAR, Aralast NP, Glasssia, Prolastin-C, and Zemaira claims and route them to the medical benefit instead of pharmacy benefit; (2) Configure system to automatically flag these medications for prior authorization requirement through GatewayPA; (3) Update provider ordering workflows and encounter documentation templates to alert prescribers that these medications now require medical prior authorization; (4) Train front desk and billing staff on the new submission process via GatewayPA portal. Failure to obtain prior authorization before service delivery will result in claim denials and payment delays. Coordinate with providers to ensure prescriptions written on or after October 1, 2026 include prior authorization requests.