CommercialCoverageHigh impact
Medical Policy and Coding Updates - September 2023
Premera Blue Cross·WA · Oncology, Hematology, Rheumatology +3 more·Medical Policy
Effective date
Dec 7, 2023
We identified it
Jun 18, 2026
Summary
Premera Blue Cross is implementing multiple policy changes affecting drug coverage tiers and medical necessity criteria. Key changes include updating several infliximab products (Avsola moving to first-line, Inflectra to second-line) and adding new oncology drugs with specific coverage criteria, effective December 7, 2023 and January 1, 2024.
Action Required
Before December 7, 2023: Billing team must update prior authorization workflows for affected medications including Temodar, Unituxin, Trazimera, Ruxience, Avsola, Inflectra, Simponi Aria, and others. Review drug tier changes to ensure proper prior authorization requirements are applied. Update encounter forms to reflect new first-line vs second-line product requirements. Notify providers of new coverage criteria for oncology drugs and autoimmune condition treatments to prevent claim denials.