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January 2015

Blue Cross individual, small group customers getting expedited Rx review process in 2015

Effective Jan. 1, 2015, Blue Cross Blue Shield of Michigan will offer a 24-hour expedited review process for individual and small group customers requesting nonformulary or urgently needed prescription drugs. Prescription drug coverage is one of the 10 essential health benefits included in the health reform guidelines for 2015.

The Centers for Medicare & Medicaid Services, or CMS, expects health insurance carriers to update their certificates of coverage to notify members of the process. CMS also expects carriers to provide instructions on how to ensure the decision is communicated to pharmacies and the pharmacy benefit manager.

For 2015, individual and small group issuers of qualified health plans that provide essential health benefits can provide a 24-hour expedited review process based on urgent circumstances. Here are the circumstances needed to trigger a 24-hour response:

  • A member, the member’s designee or the member’s prescribing doctor can request an expedited exception process based on urgent circumstances.

    Note: Blue Cross must be able to accept the information electronically, in writing or by telephone.

  • The doctor must provide an oral or written statement explaining:
    1. An urgency exists.
    2. Harm could result to the member if the drug isn’t provided in the timeframe specified in the Blues standard drug exception process.
    3. Justification supporting the need for the nonformulary drug to treat the member’s condition. One of the following statements must apply to all covered formulary drugs on any drug:
      • The drug will be or has been ineffective.
      • The drug would not be as effective as the nonformulary drug.
      • The drug would have adverse effects.

CMS notes that carriers are not required to cover medication during the review process.  When circumstances are deemed to fall under the rule, Blue Cross must respond to the request within 24 hours and make sure that approved prescription drugs are made available to the member for the duration of the authorization period.

Once a decision to expedite is made, Blue Cross will:

  • Verbally notify the member and the provider of Blue Cross’ decision.
  • Send a written letter to the member about the decision.
  • Send a fax or letter to the provider about the decision.
No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.