Physician Administered Drugs

Prior Authorizations

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 speciality drugs subject to EAPG carveout with an approved, member-specific PA
Spinraza (nusinersen)
- Coverage Standards and Request Form
Request Form - To be used for current outpatient hospital specialty drug PA requests, excluding Spinraza
Zolgensma (onasemnogene abeparvovec-xioi)
- Coverage Standards
Brineura (cerliponase alfa)
- Coverage Standards
Kymriah (tisagenlecleucel) and Yescarta (axicabtagene ciloleucel)
- Coverage Standards

Contact Information

If you need any further information, please contact Felecia Gephart at Felecia.Gephart@state.co.us.

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Physician Administered Drugs