Winter

REQUIREMENTS: 1. IMMEDIATE (within 7 days): Billing and clinical teams must review and implement the prior authorization verification best practices outlined on page 4: (1) Verify member eligibility via 1-800-279-1878 or Availity Portal; (2) Use ProPat tool to verify prior authorization requirements; (3) Verify service coverage via DMAS Fee Schedule. Update billing system workflows to enforce these three verification steps before claim submission. Flag any claims missing prior authorization as high-risk denials. 2. BEFORE January 1, 2026: Pharmacy and billing teams must update medication formulary rules and prior authorization protocols for specialty medications per the December 2025 P&T Committee decisions. Specifically: (a) Add adalimumab-adbm (Cyltezo) and adalimumab-bwwd (Hadlima) as PREFERRED tier with max dose 40mg documentation requirement; (b) Move adalimumab (Humira) to NON-PREFERRED tier as branded reference product; (c) Add Pyzchiva (Stelara biosimilar) as PREFERRED tier. Program system to automatically transition active authorizations for current Humira users to preferred biosimilar alternatives and notify prescribers. Update prior authorization templates and letter language accordingly. 3. IMMEDIATE: Front desk and clinical staff must educate providers and members about newly covered doula services. Doula care now requires: (a) provider recommendation from PCP, OB/GYN, therapist, or other identified professional; (b) completion of Doula Care Recommendation Form before services begin; (c) form submission to AetnaBetterHealthVA-CaseManagement@Aetna.com or fax 860-807-4933. Add doula referral workflow to OB/GYN and family medicine encounter templates. Do not process doula claims without completed recommendation form. 4. ONGOING: Ensure all obstetric and family medicine providers receive and review the Value-Added Benefits Member Guide (reference: AetnaBetterHealth.com/Virginia/whats-covered.html) to counsel patients on eligibility and access to doula services, behavioral health coordination, and other benefits. CONSEQUENCES: Claims submitted without verified prior authorization, completed doula recommendation forms, or using non-preferred formulary medications will be denied. Failure to transition active Humira authorizations to preferred biosimilars may result in member coverage gaps and prescriber appeals.