CommercialCoverageHigh impact
Mutual News May 2024 Newsletter
Medical Mutual of Ohio·Mutual News Newsletter
Effective date
Jan 1, 2025
We identified it
Jun 20, 2026
Summary
Effective January 1, 2025, Medical Mutual will require hospitals to obtain select specialty medications for outpatient infusions from in-network specialty pharmacies only. Hospitals that obtain these medications from other sources will have their claims denied, and they cannot bill patients for these medications.
Action Required
By January 1, 2025: Hospital billing teams must establish contracts with Medical Mutual's in-network specialty pharmacies for select specialty medications used in outpatient infusions. Update billing workflows to ensure specialty medications are sourced from in-network pharmacies only when billing on UB-04 forms. Continue billing for administration services but do not bill for the medications themselves when supplied by in-network specialty pharmacies. Review Medical Mutual's Commercial and Exchange Prior Authorization List to identify affected medications. Contact Provider Contracting Manager at 800-625-2583 for questions. Claims for affected medications from non-network sources will be denied starting January 1, 2025.