2021-02: Medicare Prior Authorization Updates Effective August 1, 2021
Date: 05/14/21
Allwell from Louisiana Healthcare Connections requires prior authorization as a condition of payment for some services. This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Allwell from Louisiana Healthcare Connections.
Allwell from Louisiana Healthcare Connections is committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the ordering physician in which we verify the medical necessity of a treatment in advance using independent objective clinical criteria.
It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization before rendering services. Providers can use our online prior authorization tool to see if a pre-authorization is needed. If an authorization is needed, you can easily access login to submit online.
Effective August 1st, 2021, Prior Authorization requirements will be changed for the following services:
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. Non-par providers and facilities require authorization for all HMO services except where indicated.
For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool.
| Drug Code | Drug Description | |
| Added to PA List | C9074 | Injection Lumasiran 0.5 MG |
| Added to Step Therapy | J0718 | Certolizumab Pegol Injection |
| Added to PA and Step Therapy | J1427 | Injection Viltolarsen 10 MG |
| Added to PA and Step Therapy | J1554 | Injection Immune Globuin Asceniv 500 MG |
| Step Therapy | J3140 | Injection, Testosterone Suspension, up to 50 MG |
| Added to PA List | J3358 | Ustekinumab, for Intravenous injection, 1 MG |
| Added to PA List | J9035 | Injection, bevacizumab, 10 MG |
| Added to PA List | J9210 | Injection, Emapalumab-LZSG, 1 MG |
| Added to PA List | Q2028 | Sculptra Injection |
| Drug Code | Drug Description | |
| Removed from PA List | J0604 | Cinacalcet Oral 1 MG |
| Removed from PA List | J8499 | Nos Drug, Oral |
| Removed from PA List | J9144 | Injection Daratumumab 10 MG and Hyaluronidase Fihj |
| Removed from PA List | J9358 | Injection Fam-Trastuzumab Deruxtecan-Nxki 1 MG |
| Removed from Step Therapy | Q5103 | Injections, Inflectra |
| Removed from Step Therapy | Q5107 | Injection Bevacizumab-Awwb Biosimilar 10 MG |
| Removed from Step Therapy | Q5118 | Injection, Bevacizumab-Bvzr, Biosimilar, (Zirabev), 10 MG |