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Medical Policy and Coding Updates - October 2023
Premera Blue Cross·WA · Oncology, Hematology, Rheumatology +4 more·Medical Policy
Effective date
Jan 1, 2024
We identified it
Jun 18, 2026
Summary
Premera Blue Cross updated medical necessity criteria for multiple drug categories effective January 1, 2024, with significant changes to first-line vs second-line treatment preferences for infliximab products, rituximab products, and other specialty medications across oncology, rheumatology, gastroenterology, and other specialties.
Action Required
By December 31, 2023: Billing team must update prior authorization workflows for specialty medications. Review all pending infliximab cases - Avsola is now first-line while Inflectra moves to second-line across psoriasis, arthritis, IBD, and autoimmune conditions. Update Ruxience (rituximab) to second-line status for lymphoma treatments. Verify G-CSF product preferences by patient age. Providers must document trial and failure requirements for migraine CGRPs (2 prophylactic medications for prevention, 1 triptan for acute). Claims may be denied without proper step therapy documentation.