Health First Colorado implemented a new utilization management (UM) program for the fee-for-service, physician-administered drug (PAD) benefit, effective January 18, 2022. A select number of PADs are subject to prior authorization (PA) requirements. PA requirements can be found listed on Appendix Y: Physician Administered Drug Medical Benefit Prior Authorization Procedures and Criteria (found below under the drop-down menu).
Providers must ensure that an approved PA is on file prior to PAD administration. Retro authorizations will be denied. There must be an approved PA on file for each of the PADs requiring a PA that a member receives. Providers should submit a PA request to the UM vendor, Keystone Peer Review Organization (Kepro), for any member receiving any of the PADs listed in Appendix Y.
All PAD PA procedures and clinical criteria can be found below on Appendix Y: Physician Administered Drug Medical Benefit Prior Authorization Procedures and Criteria. Providers will be required to follow all General Provider and PAD billing policies found in the PAD billing manual located on the Billing Manuals webpage.
PAs may be submitted and will be processed via the ColoradoPAR: Health First Colorado Prior Authorization Request Program.. Kepro has various recording training and user guides that can be found at
All other PAD questions can be directed to.
- Appendix Y: Physician Administered Drug Medical Benefit Prior Authorization Procedures and Criteria
Appendix Y Effective May 1, 2022 Effective January 18, 2022
- Outpatient Hospital Specialty Drugs - EAPG Carveout
- Appendix Z - List of current outpatient hospital specialty drugs subject to EAPG carveout with an approved, member-specific PA
- Spinraza (nusinersen)
- Request Form - To be used for current outpatient hospital specialty drug PA requests, excluding Spinraza
- Danyelza (naxitamab)
- Zolgensma (onasemnogene abeparvovec-xioi)
- Brineura (cerliponase alfa)
- Kymriah (tisagenlecleucel) and Yescarta (axicabtagene ciloleucel)
Other Resources and Links
- PAD Billing Manual
- Appendix X: HCPCS-NDC Crosswalk
- PAD Fee Schedule
- Pharmacist Services Billing Manual
- 340B Policy and Procedures Manual
If you need any further information, please email HCPF_PAD@state.co.us.
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