Physician Administered Drugs
The Department has announced the intent to award the Utilization Management (UM) contract to Keystone Peer Review Organization (KEPRO). KEPRO will replace eQHealth Solutions, Inc as the UM Vendor in Spring of 2021.
Additionally, the Department will be adding a select group of Physician Administered Drugs (PADs) to require prior authorization that will be implemented with KEPRO. Information pertaining to PAD prior authorization requests will be posted on this page within the coming weeks. Proposed PADs to be prior authorized will be reviewed at the February Drug Utilization Review (DUR) Board meeting; DUR specific information can be found on the DUR web page.
- Fee for Service Physician Administered Drugs
COMING SOON: Appendix Y - Physician Administered Drug Medical Benefit Prior Authorization Procedures and Criteria
- 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
- 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 Enrollment: Over-the-Counter and Immunizations
- 340B Information
If you need any further information, please contact Felecia Gephart at Felecia.Gephart@state.co.us.
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