Authorizations

Generations Advantage Part B Step Therapy for Drugs & Biologics Begins January 1, 2022

  • Only non-preferred products will require prior authorization. Product-specific drug authorization request forms are now available. These forms should be completed and submitted with your request along with supporting medical records. 
  • For members who’ve already received treatment with a non-preferred product within the past 365 days, step therapy requirements do not apply but prior authorization is still required. On the drug-specific authorization form there is a checkbox to indicate prior use of the non-preferred product.
  • NDCs are required on ALL (preferred and non-preferred) step therapy drug claims and on some authorization request forms.
  • Authorization requests for non-preferred products can be submitted now for services in January 2022.
  • Avastin (bevacuzimab) is preferred for ocular conditions and non-preferred for cancer indications. Authorization is only required for non-ocular-related treatments.
  • When the same HCPCS code (i.e., J0256 or J9217) is used for a preferred and non-preferred product, the NDC will be used to determine authorization requirement for that code in the claims system. The NDC will be required on the authorization form.
  • Unlisted codes require prior authorization when used for a preferred product.
  • Authorization requests for non-preferred products can be submitted now for services in January 2022

For a list of preferred drugs please see our Part B Step Therapy Drug List (PDF)

Drug-Specific Authorization Forms (fill out and submit with your request)

Authorization Instructions

Prior Authorization

  • For prescriptions, please visit our Pharmacy page.
  • For mental health/substance abuse services for Generations Advantage Plan members call BHCP at 1-800-708-4532.
  • For mental health/substance abuse services for US Family Health Plan members call BHCP at 1-888-812-7335.
  • Imaging Services for Generation Advantage members ONLY: eviCore manages authorizations for the following advanced imaging services:
  • For both Generations Advantage and US Family Health Plan members, prior authorization may be requested by the member's PCP or by the servicing provider/facility.
    • Prior authorization is not required for emergency care.
    • Prior authorization requests should be submitted at least 14 calendar days prior to the date of service or facility admission.
    • If the servicing provider is not part of the Martin’s Point network, we require a letter of medical necessity (including clinical documentation) explaining why the service(s) can only be provided by this specialist.

www.eviCore.com/healthplan/Martins_Point

Retrospective Authorization

Please refer to the Forms and Documents section for more information.

Questions? Read more in the Provider Manual or Contact Us.