Additional practitioner-administered specialty drugs to require prior authorization

Thirteen specialty drugs administered by health care practitioners will require prior authorization by BCBSM in order to be covered under members’ medical benefits, starting Jan. 22.

The Blues have delayed the expansion of its specialty drug prior authorization requirement to cover 12 additional drugs. We told you in October that the new requirement would start Jan. 1.

The selected specialty drugs are not self-administered; they require administration (injection or infusion) by a physician or other health care professional.

To be eligible for payment for these 13 medications, the ordering physician is responsible for obtaining prior authorization and verifying patient benefits. If a prior authorization is not obtained before services are rendered, the claim will be rejected. At that time, a physician can still submit a request and obtain authorization, even though the patient has already received the medication. However, the patient still needs to meet all of the requirements and have the necessary coverage in order for the claim to be payable.

Please remember that prior authorization is not a guarantee of payment.

Health care practitioners may begin submitting the preauthorization requests Jan. 10 for therapy that begins Jan. 22 or later. Requests should be submitted by the ordering provider, not the administering provider. We will process standard prior authorization requests within 15 days and urgent requests within 72 hours. Authorizations will usually grant approval for 12 months, but letters to both the physician and member will clearly state the approval time frame. If therapy is needed past that date, physicians can submit prior authorization requests for renewals to extend the therapies.

The Blues made a change to the list of drugs included in the program since we published that in October. (Synagis^® was deleted.) Specialty drugs that will require prior authorization starting Jan. 22 are:

Most members currently receiving six of these specialty drugs may continue therapy until the date listed below. At that time, physicians will need to obtain prior authorization in order to renew treatment with the drugs.

BCBSM is creating this specialty drug utilization management program to respond to concerns from many of our major group customers about potential safety issues and appropriate utilization of these high-cost medications. We will continue to add drugs to the program that will require prior authorization of new drug therapies.

The program is nationwide, meaning that it applies even when BCBSM members live or travel outside of Michigan. But the requirements do not apply to members of the following groups: Medicare, Federal Employee Program^®, State of Michigan, MPSERS, Chrysler, Ford, General Motors, UAW Retiree Medical Benefits Trust, Michigan Conference of Teamsters Welfare Fund and United Food and Commercial Workers. The requirements also do not apply to coordination of benefit claims when BCBSM is not the primary payer.

We’ll continue to update you as new drugs are added to the prior authorization requirement. You can always find a complete list of these medications that require prior authorization on web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• Click on Physician administered medications (on the right side under Frequently used forms).

We will use a vendor, NovoLogix^®, to help process the prior authorization requests through a secure online tool. Our Blues clinical team will continue to review requests against our clinical criteria. In the future, the online NovoLogix tool will allow physicians to obtain real-time status checks on prior authorizations and immediate approvals for certain medications when patients meet the criteria. Please see the article for information about training for this process.