Medicaid and CHIP Clinician-Administered Drug Prior Authorization Updates
Date: 10/29/20
Superior HealthPlan requires Prior Authorization (PA) for many Clinician-Administered Drugs (CADs) provided to Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP members.
Effective July 1, 2020, the following changes were made to PA requirements:
HCPCS Code | Description | Prior Authorization Requirements |
|---|---|---|
Q5115 | INJECTION RITUXIMAB-ABBS BIOSIMILAR 10 MG (TRUXIMA) | PA is required for all providers for diagnosis Rheumatoid Arthritis. For all other diagnoses, PA is required for all providers except when services are rendered by an internal medicine provider, hematologist or oncologist. |
Q5119 | INJECTION RITUXIMAB-PVVR BIOSIMILAR 10MG (RUXIENCE) | PA is required for all providers for diagnosis Rheumatoid Arthritis. For all other diagnoses, pre-authorization is required for all providers except when services are rendered by an internal medicine provider, hematologist or oncologist. |
Effective October 1, 2020, the following changes were made to PA requirements:
HCPCS Code | Description | Prior Authorization Requirements |
|---|---|---|
J9312 | INJECTION RITUXIMAB 10 MG (RITUXAN) | PA is required for all providers. |
Providers may submit a PA request by:
- Utilizing Superior’s Secure Provider Portal.
- If you are not currently registered on the portal, registration is quick and simple.
- Faxing an authorization to the Superior HealthPlan Pharmacy Department at 1-800-690-7030.
As a reminder, providers may determine which specific codes require PA by visiting Superior's Pre-Auth Needed Tool and selecting Medicaid.
For questions regarding this information, please contact your dedicated Account Manager or call Provider Services at 1-877-391-5921.