No prior authorization required for:
- Emergency room
- Skilled nursing facility
Injectable auth/billing notes:
Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.
Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.
Notes: Per 10mg; biologic treatment for moderate to severe chronic plaque psoriasis.
Length of initial authorization: 3 months.
Length of continuation authorization: 3 months. Two courses of therapy must be separated by at least 3 months.
Criteria for coverage:
- Diagnosis of chronic moderate to severe plaque psoriasis affecting > 10% of BSA (unless hands, feet, head and neck, or genitalia)
- Documented trial of one topical agent, one systemic treatment, and phototherapy
- Once criteria are met, review for annual renewal of authorization. You should not need to resubmit documentation.