CommercialPrior AuthHigh impact
Medical Policy and Coding Updates - November 2023
Premera Blue Cross·WA, AK · Neurology, Oncology, Rheumatology +3 more·Medical Policy
Effective date
Dec 7, 2023
We identified it
Jun 18, 2026
Summary
Premera Blue Cross updated medical necessity criteria for multiple drug categories with different effective dates from December 2023 to February 2024. Key changes include moving certain cancer and autoimmune drugs between first-line and second-line status, adding new coverage criteria for various medications, and updating prior authorization requirements for specialty drugs.
Action Required
By February 7, 2024: Billing team must update prior authorization workflows for botulinum toxin treatments to include new cervical dystonia criteria excluding acute cases caused by dopamine receptor-blocking drugs. By January 1, 2024: Update drug formulary preferences in billing system - move Trazimera and Ruxience to second-line status, promote Simponi Aria and Avsola to first-line for autoimmune conditions, and downgrade Inflectra to second-line across multiple therapeutic areas. Immediately effective December 7, 2023: Stop authorizing dry needling of myofascial trigger points as it is now considered investigational. Review all pending authorizations for affected drugs and resubmit with updated medical necessity documentation.