2025 Prior Authorization Guidelines for Certain Medications

As of 1/1/2025, some medically administered drugs like injectables may require utilization management such as a prior authorization to determine appropriateness of care, while ensuring safe and effective use. Milliman Criteria is used as a guideline to support clinical decisions. Members on the effected monoclonal antibodies and antineoplastics in 2024 that are requiring a PA in 2025, will be grandfathered in 2025.

If you believe that these options are not right for your patient, please send us (Medical Management team) documentation by fax (866) 791-2214 indicating why your patient cannot use the preferred alternative(s). This documentation can include a summary of the patient’s medical history and treatment rationale, as well as recent medical records such as office visit notes.