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)

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:
- Non Cardiac CT, MRI, PET and Nuclear Medicine services
- Call eviCore at 1-888-693-3211 OR use eviCore’s self-service web portal at www.eviCore.com/healthplan/Martins_Point
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.

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

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