All PlansPrior AuthHigh impact
Medical Policy and Coding Updates - October 2022
Premera Blue Cross·WA, AK · Rheumatology, Gastroenterology, Oncology +7 more·Medical Policy
Effective date
Oct 1, 2022
We identified it
Jun 18, 2026
Summary
Major policy updates effective October-December 2022 include new prior authorization requirements for Krystexxa® (must be given with methotrexate), Tysabri® (requires TNF blocker trial failure), and site of service restrictions for Cutaquig® infusions. Multiple drug coverage changes, medical necessity criteria updates, and investigational determinations affect billing across specialties.
Action Required
By December 1, 2022: Update prior authorization protocols for Krystexxa® to require concurrent methotrexate 15mg weekly documentation and Tysabri® to require TNF blocker trial failure documentation. By November 4, 2022: Ensure Cutaquig® is billed as infusion service per site of service requirements. Immediately: Update formulary systems with all new drug additions, removals, and investigational determinations. Train staff on new medical necessity criteria for orthoses, hyperbaric oxygen, and monitoring services.