Medica reserves the right to conduct a medical necessity review at the time the claim is received.
Medical Benefit Applies
Prior Authorization for Medical Benefit Drugs
Medica requires prior authorization for certain drugs administered under a Medica member's medical benefit. This program is managed by Magellan Rx. Effective with January 1, 2018, dates of service, hemophilia products will need prior authorization as well.
Affected drug policies are available on the Magellan Rx website.
Affected drug policies
Medica's Site of Service program, also administered by Magellan Rx, addresses where infusion drugs are best provided for certain Medica members.
View Medica's Site of Service policy
Resources:
Medical Pharmacy Claims – Edit Policies
For certain medications billed under the member’s medical benefit, Medica applies pre-payment claims edits to diagnosis criteria and criteria for maximum units. As outlined in Medical Pharmacy Claims-Edit Policies for these medications, these edits verify that claims are paid in accordance with each policy’s stated clinical criteria as well as the maximum units previously authorized.
This program is administered by Magellan Rx.
Note: Prior authorization criteria will not apply for all of these policies, necessarily, and this will be noted in each respective policy.
View affected drug policies at Magellan Rx