CommercialPrior AuthHigh impact
Medical Policy and Coding Updates - December 2023
Premera Blue Cross·WA · Oncology, Hematology, Rheumatology +5 more·Medical Policy
Effective date
Mar 17, 2024
We identified it
Jun 18, 2026
Summary
Premera Blue Cross updated multiple medical policies and clinical appropriateness guidelines effective at various dates from December 2023 through March 2024. Key changes include updates to genetic testing criteria, therapeutic radiopharmaceuticals coverage, drug tier changes for biologics like infliximab products, and revised medical necessity criteria for various specialty medications.
Action Required
By March 17, 2024: Billing team must update prior authorization requirements for genetic testing services including cell-free DNA testing, somatic tumor testing, and prenatal testing per new Carelon Medical Benefits Management guidelines. By March 7, 2024: Implement new prior auth requirements for therapeutic radiopharmaceuticals including Azedra, Xofigo, and Zevalin. By February 7, 2024: Update medical necessity documentation requirements for botulinum toxin treatments. Immediately: Update drug formulary preferences - change Avsola to first-line and Inflectra to second-line for infliximab products across multiple conditions. Review all specialty drug protocols for updated medical necessity criteria. Failure to obtain required prior authorizations will result in claim denials.