MedicaidPrior AuthHigh impact
BT202296: IHCP updates physician-administered drug PA criteria and diagnosis restrictions
Indiana Medicaid (IHCP)·IN · Oncology, Hematology, Neurology +2 more·Pharmacy
Effective date
Dec 9, 2022
We identified it
Jun 19, 2026
Summary
Indiana Health Coverage Programs (IHCP) updated prior authorization criteria for several physician-administered drugs effective December 9, 2022. The changes include new PA requirements for drugs like Lutathera, Adakveo, and several DMD treatments, with specific age, diagnosis, and treatment history requirements that must be documented for approval.
Action Required
By December 9, 2022: Billing team must update prior authorization workflows for codes A9513, J0791, J1426, J1428, J1429, J2326, J2507, and J3032. Providers must document specific criteria including patient age, confirmed diagnoses, previous treatments, dosing based on patient weight, and clinical status assessments. Update encounter forms and EMR templates to capture required documentation elements. Claims without proper PA and documentation will be denied.