Provider Criteria Change

By November 11, 2026: (1) Billing team must update prior authorization system rules in billing software to reflect new authorization renewal criteria for paliperidone palmitate monthly formulation (manageable/no side effects AND condition stable/improved) and for 3-month and 6-month formulations (condition improved AND manageable/no side effects). (2) Update clinical criteria validation rules to include the new 6-month formulation (Invega Hafyera/J2428) requiring either 4+ months on Invega Sustenna with last two doses at same strength OR 3+ months on Invega Trinza. (3) For Teplizumab-mzwv (Tzield/J3358), implement prior authorization requiring Stage 2 Type 1 Diabetes confirmation via specific autoantibody panels and dysglycemia criteria; add age restriction validation (1+ years for Stage 2; 8-17 years for Stage 3); validate exclusion criteria (lymphocyte count, platelet count, liver function, EBV/CMV status, active infections). (4) Update authorization request forms to require psychiatrist consultation for paliperidone and endocrinologist consultation for Tzield. Providers should verify all clinical documentation before claim submission. Claims lacking required prior authorization or missing clinical criteria documentation will be denied.