HEDIS medical record reviews begin in February

Each year, from February through May, Blue Cross Blue Shield of Michigan conducts Healthcare Effectiveness Data and Information Set, or HEDIS^®,** medical record reviews. This year, Inovalon™ will conduct HEDIS reviews for Blue Cross commercial PPO, Medicare Plus Blue℠ PPO and Blue Cross^® Medicare Private Fee for Service members for the 2017 measurement year.

For the HEDIS reviews, Inovalon looks for details that may not have been captured in claims data, such as blood pressure readings, HbA1c lab results, colorectal screenings and body mass index. This information helps us improve our member quality initiatives.

Inovalon will contact you to schedule an appointment for a HEDIS review or request that you fax the necessary records. The HEDIS review also requires proof of service documentation for data collected from a medical record.

These reviews are in addition to the out-of-state medical record reviews that Inovalon conducts for the Blue Cross Blue Shield Association.

To give you a look ahead at all 2018 chart reviews, see the table below.

**HEDIS^® is a registered trademark of the National Committee for Quality Assurance.

Medicare Advantage PPO, PFFS high-cost claims process changes coming soon

We’re changing our process so we can better handle high-cost inpatient acute care and long-term care claims for group and individual Medicare Advantage PPO and Medicare Advantage Private Fee-for-Service members that result in diagnosis-related group outlier payments.

Our goal is to:

• Improve payment accuracy.
• Avoid overpayment recoveries.
• Control unnecessary costs.
• Have all claims paid correctly the first time.

To accomplish this, we’ve established a strategic relationship with Equian, an industry leader in prepayment solutions. In March 2018, Equian will begin reviewing inpatient claims to detect and resolve errors before payment. Equian’s service delivery model and advanced analytics allow completion of timely reviews using only an itemized bill.

How the process will work

• Inpatient acute hospitals and long-term care providers will submit their inpatient claims as they do today.
• If the claim includes a DRG outlier payment, submit an itemized bill.
• Submit itemized bills with the applicable cover sheet by fax to 1-844-214-8520 or mail:
  

• Medicare Plus Blue
  Blue Cross Blue Shield of Michigan
  P.O. Box 32593
  Detroit, MI 48232-0593

• A claim that meets the prepay criteria will pend (or freeze) in our claims system.
• We’ll review claims with a DRG outlier payment.

Itemized bill requirements

To complete the review and process the claim, Blue Cross needs your itemized bill. If we haven’t received your itemized bill when the claim is ready for review, we’ll deny the claim. If the itemized bill is received after the claim has denied, we’ll proceed with Equian’s review of the itemized bill and adjust the claim to allow payment. You won’t need to contact us to initiate this process. Also:

• Blue Cross will give the itemized bill to Equian for review.
• Equian’s review will focus on ensuring that you’re billing claims according to Blue Cross guidelines.
• Equian will complete the review within five days and return it to Blue Cross.
• Blue Cross will review Equian’s findings on the claim within five days, determine what changes (if any) will need to be made to the claim and then process the claim.
• Equian will send the results to you through the Forensic Review Report.

What happens next?

After the review is complete, Equian will follow up with you to address any questions they may have or to clarify the findings.

We’ll publish more details about this program in the April Medicare Advantage PPO and PFFS provider manual updates.

Note: To submit a request to update specific contact information for Blue Cross MA members, providers should email MedicareAdvantagePrePayForensicReview@bcbsm.com.

Clear Claim Connection™ getting new look, new data fields

In the first quarter of 2018, Blue Cross Blue Shield of Michigan will launch an upgrade for ClaimsXten. This upgrade will bring a new look to Clear Claim Connection, along with new data fields on the Claim Entry and Audit Results screens.

Claim Entry updates
You’ll be able to add 10 more lines to the Claim Entry screen by clicking the Add More Procedures >> line (which will be directly under the procedure code entry field). But it might be necessary to group category of services together for claim-line entries greater than 20. New fields are shown here:

Audit Results updates
The following new fields will affect the ClaimsXten recommendation:

• Claim Type — It’ll indicate if the claim is professional or facility.
• Qty. — If the quantity exceeds the allowed maximum, the RECOMMENDATION field will show DISALLOW. A line with the maximum allowed quantity will appear with the recommendation, ALLOW-ADD.
• RVU — Relative value units will return on a pay-percent recommendation only.

About Clear Claim Connection
C3 is a web-based solution for Michigan professional and outpatient facility providers. It mirrors the clinical editing software we use to evaluate code combinations for medicine, surgical, laboratory and radiology services. And it allows you to view the clinical rationale behind clinical edits.

To launch C3:

1. Go to bcbsm.com and log in to your provider account.
2. Click Login to Secured Services, and enter your ID and password.
3. Click Clear Claim Connection. Note: If your ID has access to other features, you may need to scroll down to see it.

If you don’t have access to web-DENIS, call our help line at 1-877-258-3932 from 8 a.m. to 8 p.m. Monday through Friday. Or complete the Provider Secured Access Application and the Use and Protection Agreement forms available on bcbsm.com and fax them to 1-800-495-0812.

Related article: ClaimsXten™ multiple radiology procedures edit rescheduled for 1Q 2018

ClaimsXten™ multiple radiology procedures edit rescheduled for first quarter 2018

With the implementation of ClaimsXten for outpatient facilities in 2016, Blue Cross Blue Shield of Michigan announced it would edit some radiology procedures that are eligible for payment reduction. However, due to a system limitation, we delayed the edit — it will now begin in the first quarter of 2018.

To submit out-of-state claims for IBU PPO members, follow these guidelines for exceptions

Beginning Jan. 1, 2018, BlueCard home claims for individual business unit PPO members will be processed through the BlueCard program. Out-of-network cost share will apply, with some exceptions.

Below are the exceptions to out-of-network cost share on home claims, if the services are part of the member’s benefits:

• Emergency
• Urgent care
• Accidental injury
• Online visits
• Dental
• Vision
• Pharmacy

There may be some circumstances in which it’s appropriate to reprocess claims to change the cost share from out of network to in-network, but such exceptions are only granted when specific criteria are met. Specific out-of-network claims can be reprocessed as in-network claims at the customer’s request without having to go through the exception approval process. These claim types are:

• Autism
• Clinical trials
• Oncology clinical trials
• Human organ transplant
• Mental health and substance abuse treatments not available in Michigan
• Services for emergency, urgent care or accidental injury services, including follow-up visits
• Member is admitted to a hospital immediately following an emergency room visit
• Member is transferred by ambulance on an emergency basis to nearest hospital equipped to handle continued care
• Claims from an out-of-state provider who can bill with a PPO Michigan PIN
• Claims from an out-of-state ancillary prosthetic and orthotic, durable medical equipment or medical supplier that can bill with a Michigan PIN
• Claims from an out-of-state provider when the services are performed at a Michigan facility
• Service has preapproval on file; only services and diagnoses that match the preapproved exception form can be adjusted as in-network

Note: Out-of-network cost share can’t be waived for out-of-state college students and Michigan residents who live outside Michigan part of the year. The member must live in Michigan throughout the calendar year.

For more information, read our blog at mibluesperspectives.com/outofstate.

Billing chart: Blues highlight medical, benefit policy changes

You’ll find the latest information about procedure codes and Blue Cross Blue Shield of Michigan billing guidelines in the following chart.

This billing chart is organized numerically by procedure code. Newly approved procedures will appear under the New Payable Procedures heading. Procedures for which we have changed a billing guideline or added a new payable group will appear under Updates to Payable Procedures. Procedures for which we are clarifying our guidelines will appear under Policy Clarifications. New procedures that are not covered will appear under Experimental Procedures.

You will also see that descriptions for the codes are no longer included. This is a result of recent negotiations with the AMA on use of the codes.

We will publish information about new BCBS groups or changes to group benefits under the Group Benefit Changes heading.

For more detailed descriptions of the BCBSM policies for these procedures, please check under the Medical/Payment Policy tab in Explainer on web-DENIS. To access this online information:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications & Resources.
• Click on Benefit Policy for a Code.
• Click on Topic.
• Under Topic Criteria, click on the drop-down arrow next to Choose Identifier Type and then click on HCPCS Code.
• Enter the procedure code.
• Click on Finish.
• Click on Search.

Medicare patients at risk for Type 2 diabetes can soon take part in new diabetes prevention program

Effective April 1, 2018, your patients with Medicare who have Part B coverage and who are at risk for Type 2 diabetes are eligible for the Medicare Diabetes Prevention Program. It’s offered at no cost to the member.

In a random controlled trial, the program was proven by the National Institutes of Health to greatly reduce the progression of prediabetes to Type 2 diabetes. Program services are delivered by lifestyle coaches in community settings. The coaches are trained by organizations that are recognized by the Centers for Disease Control and Prevention.

Medicare criteria for eligibility are:

• Enrollment in Medicare Part B
• Blood value (one of the following):
• Fasting plasma glucose of 100-125 mg/dL
• A1c value between 5.7-6.4
• Oral glucose tolerance test between 140-199 mg/dL
• Body mass index greater than 25 (if Asian, greater than 23)
• No diagnosis of end-stage renal disease, Type 1 or Type 2 diabetes; previous gestational diabetes isn’t an exclusion to participation.

Information about how eligible members can enroll in the MDPP through our program administrator, Solera Health, will be available soon on web-DENIS. We’ll also provide enrollment details in the March Record.

Physician organizations receiving additional information to help providers address opioid epidemic

As part of Blue Cross Blue Shield of Michigan’s continuing efforts to address the opioid epidemic, Value Partnerships, in partnership with Pharmacy Services, is accelerating efforts on multiple fronts to further reduce fraud and the abuse of controlled substances.

Our current Fraud, Waste and Abuse Program already identifies the following:

• Health care providers who are writing an opioid prescription for a patient who may be “doctor shopping,” the practice of visiting multiple physicians to obtain multiple prescriptions.

• Patients who have been prescribed part or all a dangerous drug combination known as the “triple threat” — concurrent use of opioids, benzodiazepines and muscle relaxants. Triple threat combinations are often linked to recreational patient use and frequently lead to overdose and even death.

Blue Cross has a longstanding practice of contacting prescribing physicians when one of these situations is occurring in case they are unaware of it. Since April 2016, Blue Cross Pharmacy Services has seen a 33 percent drop in members identified in our doctor shopper analysis and a 54 percent drop in members receiving the dangerous triple threat drug combination.

In December, we began bringing our Physician Group Incentive Program participating physician organizations into the loop so that they, too, receive monthly reports of their member physicians who could unknowingly be involved in one of these potentially dangerous scenarios.

This process change provides us with an additional venue for educating providers about the importance of using the Michigan Automated Prescription System, or MAPS. The tool, provided by the State of Michigan, helps prescribers identify patients who may be improperly seeking Schedule 2 to 5 drugs. It’s used to identify and prevent drug abuse and diversion at the prescriber, pharmacy and patient level.

For more information, go to michigan.gov/mimapsinfo** or reach out to your physician organization.

New flyer on opioid epidemic
To learn more about what Blue Cross and Blue Care Network are doing to battle the opioid epidemic, see the flyer we recently developed. It provides updated statistics about the opioid epidemic, outlines our comprehensive strategy and shows results from our various initiatives.

** Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Online health assessment helps your patients identify their health risks

Looking for a tool that can help your patients pinpoint their health risks?

Blue Cross Blue Shield of Michigan’s online health assessment on the Blue Cross^® Health & Wellness website can provide you with the support you need. It gives our members an easy and convenient way to see how their lifestyle choices affect their health and find out more about their modifiable health risks.

When your patients with Blue Cross coverage take the health assessment, they receive immediate feedback. It includes a results report that explains their risk levels, recommendations and referrals that provide them with an easy first step into action and a health risk score that helps encourage positive changes. They can print this information to share with you. This is a great way for you to get a snapshot of your patients’ health risks so you can work with them on ways to lower those risks.

The health risk score is derived from an analysis of their modifiable health risks. These include:

The Blue Cross health assessment uses engaging graphics and easy-to-read questions that guide our members through a series of modules that assess various aspects of their lifestyle, health conditions, well-being and more. It also asks questions that assess a member’s readiness to make changes. Members are asked to input various biometric screening results; Blue Cross members who use the qualification form or attend a Blue Cross worksite health screening event will have their test results automatically uploaded into the health assessment.

Fast and easy to use
The health assessment only takes a few minutes to complete, and it’s intuitive and user-friendly. Your patients with Blue Cross coverage can take the health assessment on their computers or mobile devices through their member account on bcbsm.com or they can take it using the Blue Cross mobile app. The Blue Cross health assessment is powered by WebMD^® and is NCQA-accredited.

WebMD Health Services is an independent company supporting Blue Cross Blue Shield of Michigan by providing health and wellness services.

Don’t resubmit professional and ancillary claims involved in audits

Blue Cross Blue Shield of Michigan is reminding providers not to resubmit any professional or ancillary claims involved in our audits. These include the following types of providers:

• M.D.s, D.O.s and specialist physicians
• Ambulance providers
• Certified registered nurse anesthetists
• DME/P&O
• Home infusion therapy
• Independent labs
• Independent physical therapy and occupational therapy
• Licensed psychologists
• Nurses
• Ophthalmology
• Oral surgery
• Pharmacy
• Podiatry
• Provider office infusion therapy
• Rheumatology
• Urgent care

Once you receive a letter and patient list notifying you of an audit and the claims that will be part of the review, these claims can no longer be adjusted even after the audit has concluded. Be sure to let your billing and finance departments know which claims are being audited so they won’t resubmit any claims until Blue Cross notifies them to do so.

Rebilling charges is time-consuming and can create additional problems once the audit process is complete and claims are submitted for adjustment.

Clarification for fourth quarter 2017 CAQH ProView™ provider attestation process

On Oct. 1, 2017, Blue Cross Blue Shield of Michigan and Blue Care Network transitioned to CAQH ProView for its provider directory attestation process. To clarify the process, moving forward, CAQH will notify you:

• For your credentialing attestation at 120 days
• For your directory attestation requirement at 90 days

Attestation every 90 days or every 120 days will satisfy both the credentialing and directory requirements.

If you have questions or need help completing your attestations, contact CAQH at 1-888-599-1771.

Reminder: It’s important for pharmacies to report patients’ vaccinations to MCIR

Pharmacies play an important role in immunizations because pharmacies are easily accessible and offer convenient locations and hours. Vaccines protect children, adolescents and adults from potentially serious vaccine-preventable diseases, including measles, pertussis, meningitis, pneumonia and influenza.

Michigan’s statewide immunization registry, the Michigan Care Improvement Registry, tracks all vaccines administered in Michigan. By law, providers are required to report all immunizations administered to every person younger than age 20 within 72 hours of administration. MCIR was expanded to a lifespan registry in 2006; reporting adult vaccinations is strongly encouraged.

Reporting data to MCIR is a good public health practice because:

• It reduces over-immunization by maintaining the patient’s immunization history.
• It helps decrease missed opportunities for vaccination.
• It allows for sharing immunization records between vaccine provider offices.

Under Schedule B of the BCBSM and BCN Restated & Amended Preferred Rx Participation Agreement, Blue Cross requires providers who administer vaccine products to do all of the following:

• Complete the required immunization training.
• Use reasonable commercial efforts to maintain and make available the provider inventory of covered vaccine products at the location the provider anticipates the eligible members may schedule their vaccine administration.
• Provide a secured area for physical storage of drugs. This doesn’t mean that the provider will have inventory or security measures outside of the normal business setting.
• Register all administered vaccines with the Michigan Care Improvement Registry or another organization as identified by Blue Cross Blue Shield of Michigan and Blue Care Network.
• Require a written prescription from a licensed prescriber for all vaccine products.**

Help your pharmacy, your patients and your patients’ other providers know which vaccines the patients have received by documenting them in the Michigan Care Improvement Registry.

For more information on participating in MCIR, visit mcir.org/providers/pharmacies.***

**Blue Cross and BCN will accept standing orders from physicians.

***Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

Corrective action affects your value-based reimbursement eligibility

Value Partnerships continues to identify innovative models to reward practitioners who improve the quality of care for members and Michigan residents. However, those in corrective action because of utilization issues may be ineligible for value-based reimbursements until amends are made.

For a designated period, doctors and specialists who participate in the Physician Group Incentive Program and meet the applicable standards of quality programs developed under PGIP receive reimbursement in accordance with the Value-Based Reimbursement Fee Schedule.

For more information

For more information about the PPO Network Management corrective action process, see the November 2012 Record article TRUST PPO network information in review.

For details on the value-based reimbursement criteria, see the following April 2016 Record articles:

• Here's what you need to know about participating in Value Partnerships quality programs
• We’re making some changes to the Value-Based Reimbursement Fee Schedule, effective July 1, 2016

If you have questions, email valuepartnerships@bcbsm.com.

We’ve made changes to Ambulance Provider Participation Agreement

As communicated in the June 2017 Record, Blue Cross Blue Shield of Michigan has a new ground and air Ambulance Provider Participation Agreement, which includes Blue Care Network. Blue Cross ambulance providers that didn’t sign the new agreement won’t be affected by this change at this time. These providers may continue to participate under the Blue Cross only agreement. However, eventually, Blue Cross may phase out the Blue Cross only agreement and only use the joint Blue Cross/BCN agreement for providers that want to participate. 

2018 criteria for medically necessary behavioral health treatment available on web-DENIS

Several medical necessity criteria for behavioral health treatment have been updated and became effective on Jan. 1, 2018. You can access these documents on web-DENIS.

For 2018, updates have been made to the following documents:

• The New Directions Behavioral Health Medical Necessity Criteria. This document identifies the criteria for medically necessary psychiatric and substance abuse treatment.

• The BCBSM/New Directions Applied Behavior Analysis Medical Necessity Criteria

• The medical necessity criteria for repetitive transcranial magnetic stimulation, also known as rTMS

You can print any of the above documents directly from web-DENIS by following these steps:

1. Log in to web-DENIS.
2. In the left-hand navigation, click on BCBSM Provider Publications and Resources.
3. Click on Newsletters and Resources.
4. Under Other Resources, click on Clinical Criteria & Resources.
5. Scroll down to the Current Behavioral Health Clinical Criteria section of the page and click on the document you wish to print.

If you have any questions, call Behavioral Health Services in the Ancillary Program Management department at 313-448-7745.

FEP Case Management program requires member’s signed consent for enrollment

Federal Employee Program^® members who want to use Case Management services must sign a Consent for Case Management form. This requirement went into effect Jan. 1, 2018.

There’s no additional cost to the member for the Case Management program and it’s voluntary. The consent is active for one year from the date signed. The consent also ends when a patient is no longer a member of the Blue Cross and Blue Shield Service Benefit Plan.

While enrolled, the member must follow the program requirements as outlined in section 5(h) of the Service Benefit Plan brochure. Consent for case management allows the case manager to contact the member or their care team to discuss health care needs and authorizes the release of medical information.

If a member is transitioning to a residential treatment facility, they must be participating in the Case Management program prior to admission in order to receive these services while in the facility. Similarly, members with the Standard Option, but no Medicare Part A coverage, must be enrolled in Case Management before entering a skilled nursing facility if they wish to receive these services while in the facility.

To get the form:

1. Log in as a provider at bcbsm.com.
2. Click BCBSM Provider Publications and Resources on the lower right side of the page.
3. Click Newsletters and Resources.
4. Click Forms in the Other Resources section in the left navigation.
5. Click Federal Employee Program Consent for Case Management.

If you have benefit questions, call the FEP Customer Service line at 1-800-482-3600. If you have questions about Case Management services, call 1-800-325-6278.

Spider vein treatment requires photos

A photo of the spider veins is required when procedure code *36468 is performed for treatment of spider veins. The photo should be kept with the medical records and submitted upon request.

2018 criteria for medically necessary behavioral health treatment available on web-DENIS

Several medical necessity criteria for behavioral health treatment have been updated and became effective on Jan. 1, 2018. You can access these documents on web-DENIS.

For 2018, updates have been made to the following documents:

• The New Directions Behavioral Health Medical Necessity Criteria. This document identifies the criteria for medically necessary psychiatric and substance abuse treatment.

• The BCBSM/New Directions Applied Behavior Analysis Medical Necessity Criteria

• The medical necessity criteria for repetitive transcranial magnetic stimulation, also known as rTMS

You can print any of the above documents directly from web-DENIS by following these steps:

1. Log in to web-DENIS.
2. In the left-hand navigation, click on BCBSM Provider Publications and Resources.
3. Click on Newsletters and Resources.
4. Under Other Resources, click on Clinical Criteria & Resources.
5. Scroll down to the Current Behavioral Health Clinical Criteria section of the page and click on the document you wish to print.

If you have any questions, call Behavioral Health Services in the Ancillary Program Management department at 313-448-7745.

Clarification for hospice providers billing for nursing home care with hospice support

When a patient meets the criteria for nursing home care with hospice support and has coverage for the fifth level of care, which includes room and board, billing varies depending on the patient’s coverage:

• If the patient doesn’t have Medicare coverage, bill Blue Cross Blue Shield of Michigan for routine home care (revenue code 0651) and room and board (0658).
• If the patient has Medicare with Blue Cross supplemental coverage, bill Blue Cross for room and board (0658) but bill Medicare for routine home care. You no longer need to include the Medicare payment amount for routine home care on the room and board claim you submit to Blue Cross.

If the patient’s Blue Cross hospice benefit doesn’t include coverage for the fifth level of care, then room and board isn’t a covered service and the patient is financially responsible for the cost.

Clinic visits no longer covered for Blue Cross Medicare facility outpatient claims

Blue Cross Blue Shield of Michigan will no longer pay clinic visits (revenue codes Y5100 to Y5190) for UAW Retiree Medical Benefits Trust members with Medicare secondary coverage. Due to a system glitch, Blue Cross had been paying many of these claims in error. While we don’t plan to recover previously paid claims, new claims for service starting Jan. 1, 2018, are being denied as a member liability. URMBT doesn’t cover clinic visits.

Claims affected by this change include group numbers 71400, 71434, 71435, 71472 and 71436.

Reminder: It’s important for pharmacies to report patients’ vaccinations to MCIR

Pharmacies play an important role in immunizations because pharmacies are easily accessible and offer convenient locations and hours. Vaccines protect children, adolescents and adults from potentially serious vaccine-preventable diseases, including measles, pertussis, meningitis, pneumonia and influenza.

Michigan’s statewide immunization registry, the Michigan Care Improvement Registry, tracks all vaccines administered in Michigan. By law, providers are required to report all immunizations administered to every person younger than age 20 within 72 hours of administration. MCIR was expanded to a lifespan registry in 2006; reporting adult vaccinations is strongly encouraged.

Reporting data to MCIR is a good public health practice because:

• It reduces over-immunization by maintaining the patient’s immunization history.
• It helps decrease missed opportunities for vaccination.
• It allows for sharing immunization records between vaccine provider offices.

Under Schedule B of the BCBSM and BCN Restated & Amended Preferred Rx Participation Agreement, Blue Cross requires providers who administer vaccine products to do all of the following:

• Complete the required immunization training.
• Use reasonable commercial efforts to maintain and make available the provider inventory of covered vaccine products at the location the provider anticipates the eligible members may schedule their vaccine administration.
• Provide a secured area for physical storage of drugs. This doesn’t mean that the provider will have inventory or security measures outside of the normal business setting.
• Register all administered vaccines with the Michigan Care Improvement Registry or another organization as identified by Blue Cross Blue Shield of Michigan and Blue Care Network.
• Require a written prescription from a licensed prescriber for all vaccine products.**

Help your pharmacy, your patients and your patients’ other providers know which vaccines the patients have received by documenting them in the Michigan Care Improvement Registry.

For more information on participating in MCIR, visit mcir.org/providers/pharmacies.***

**Blue Cross and BCN will accept standing orders from physicians.

***Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

High-cost insulins with comparable alternatives are included among Blue Cross, BCN’s Custom Select Drug List exclusions

To address the high cost of drugs and provide the best value for our members, Blue Cross Blue Shield of Michigan and Blue Care Network commercial (non-Medicare) plans exclude drugs from the Custom Select Drug List when there is a more cost-effective alternative available.

Insulin exclusions

Blue Cross and BCN commercial plans won’t cover all formulations of the following insulin products for the Custom Select Drug List, effective Jan. 1, 2018:

• Apidra^®, Apidra^® Solostar^®
• Humalog^® (except Junior KwikPen), Humalog^® Mix
• Humulin^® (except U-500), Humulin^® KwikPen^®

Members who use these insulin products can continue to fill prescriptions for them through March 1, 2018. This will give them the opportunity to talk to their providers about treatment options.

Insulin products of the same type are interchangeable and work the same way to lower A1c. The following table shows what is and isn’t covered and the cost implications:

Other exclusions
In addition to the high-cost insulin, we’ve listed other drugs below that we removed from our Custom Select Drug List, effective Jan. 1, 2018. And we’ve also listed some covered alternatives:

**Indicates that there is no generic version of the alternative drug currently available

We’ll continue to identify certain high-cost drugs and will stop covering them when there are more cost-effective alternatives available for our commercial members.
The Custom Select Drug List is found on bcbsm.com, on our Pharmacy Services page.

Starting March 1, 2018, prescriptions for all growth hormone products will have mandatory prior authorization requirements

At Blue Cross Blue Shield of Michigan and Blue Care Network, we regularly review drug therapies as an extra safeguard to ensure we cover the right medication for the right situation.

Beginning March 1, 2018, growth hormone products will require approval before Blue Cross and BCN will cover them under their prescription drug plan.

A few points to remember

• Drug approval requirements for coverage and all drug lists can be found online at bcbsm.com/pharmacy.
• Pediatric members and adult members have different coverage requirements.
• We cover nonpreferred growth hormone products after the member tries all preferred products and finds them not effective.

Here’s the copayment levels for growth hormone products: