Prior Authorizations
PAD PAR Frequently Asked Questions
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 Kepro PA portal. Kepro has various recording training and user guides that can be found at ColoradoPAR: Health First Colorado Prior Authorization Request Program.
All other PAD questions can be directed to HCPF_PAD@state.co.us.
Appendix Y: Physician Administered Drug Medical Benefit Prior Authorization Procedures and Criteria
| Appendix Y |
|---|
| Effective April 1, 2024 |
| Effective January 1, 2024 |
| Effective July 1, 2023 |
| Effective January 1, 2023 |
Hospital Specialty Drug Policy
Hospital Specialty Drug Policy and Prior Authorization Procedures
- Hospital Specialty Drug Carveout Consideration Form - To be used to request a medication be considered for the Hospital Specialty Drug Policy
- Appendix Z - This is a resource list of the medication names and coverage standards of the current Hospital Specialty Drugs which are carved out from either the All-Patient Refined Diagnosis Related Group (APR-DRG) or the Enhanced Ambulatory Patient Group (EAPG) payment with an approved, member-specific prior authorization (PA).
For the corresponding Healthcare Common Procedure Coding System (HCPCS) codes and National Drug Code (NDC) numbers for use in billing, please refer to Appendix X: The HCPCS/NDC Crosswalk for billing Physician Administered Drugs (PADs). - Spinraza (nusinersen)
- Request Form - To be used for current hospital specialty drug PA requests, excluding Spinraza
Other Resources and Links
- PAD Billing Manual
- Appendix X: HCPCS-NDC Crosswalk
- PAD Fee Schedule
- Pharmacist Services Billing Manual
- 340B Policy and Procedures Manual
Contact Information
If you need any further information, please email HCPF_PAD@state.co.us.
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