Policies and Guidelines

Drug Management Policies

Drug Coverage Policies

Important note: Before using these policies, read Coverage Policy Usage Notice.

• Antineoplaston Therapy and Sodium Phenylbutyrate* (PDF) 
• BioIdentical Hormone Replacement Therapy* (PDF) 
• Botulinum Toxin (BTX) Treatment for Non-Cosmetic Indications (PDF) 
• Chelation Therapy* (PDF) 
• Compounded Sublingual, Oral, or Intranasal Allergenic Extracts for Allergy Diagnosis and/or Immunotherapy* (PDF)
• Eteplirsen (Exondys 51™) – (PDF)
• Herpes Zoster Vaccine* (PDF) 
• Hydroxyprogesterone Caproate (Makena)* –(PDF)
• Insulin Potentiation Therapy* (PDF)
• Intra-articular Hyaluronan Therapy (Viscosupplementation) – (PDF)
• New-to-Market Medical Pharmacy Products (PDF)
  •  New-to-Market Medical Pharmacy Products Currently Under Clinical Review (PDF)
• Use of Injectable Ketamine (Ketalar^®) for Treatment of Mental Health Conditions* (PDF)

*These policies also apply to Mayo Medical Plan (for Mayo Clinic employees)

Prior Authorization Policies

Before using these policies, read Utilization Management Policy Usage Notice.

Important Note for Medical Benefit Drugs: It is required that prior authorization be obtained before services are rendered. Beginning with January 1, 2014, dates of service, if any items on the Medica Prior Authorization List are submitted for payment without obtaining a prior authorization, the related claim or claims will be denied as provider liability. The provider will have 60 days from the date of the claim denial to appeal and supply supporting documentation required to determine medical necessity.

Claim Appeal Request Form (DOC)

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:

• Prior Authorization Fax Form (PDF) – general form for all drugs
• Prior Authorization Form for Hemophilia (PDF) – for referring providers
• Case Review Form for Hemophilia (PDF) – for rendering pharmacies

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