Utilization management program to include medical drugs administered to outpatients in hospital setting

Blue Cross Blue Shield of Michigan is expanding its Medical Drug Utilization Management Program to include medical drugs administered to hospital outpatients, starting Jan. 1, 2016. The program has required prior authorization for services rendered in a professional setting since 2013.

The select drugs require administration (injection or infusion) by a physician or other health care professional. The health care practitioner who is treating the patient for the disease state and orders the drug treatment is responsible for obtaining authorization and verifying patient benefits. A prior authorization is required whether the administration is in an office, hospital-based infusion center, clinic or outpatient hospital that submits billing on a UB-04, but it is not a guarantee of payment.

Ordering practitioners may begin submitting requests Dec. 14, 2015, for therapy that begins Jan. 1, 2016, or later for services rendered in an outpatient hospital setting. If prior authorization is not obtained before services are rendered, the service will be rejected. The ordering provider can request an authorization after the patient receives medications. However, the patient still needs to meet all of the requirements and have the necessary coverage in order for the claim to be payable.

We won’t consider a request for coverage until we receive a physician-signed medication authorization request form either faxed to Blue Cross or a request uploaded to the online-based tool NovoLogix^®. Standard processing time for review of a request is 15 days. An urgent request is reviewed within 72 hours.

You can find the form linked within the current list of medications that require prior authorization, as well as a list of groups that have opted out, on web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• From this page, click on Pharmacy prior authorization/Step Therapy forms link at the top of the page
• Click on Physician administered medications link

Our Blue Cross clinical team will continue to review requests based on our clinical criteria. Ordering physicians can get real-time status on prior authorizations and immediate approvals for certain medications when patients meet the criteria by using the secure online tool, NovoLogix.

We’ve included criteria for authorization and the medication request forms on the medical router for in- and out-of-state physicians. In-state physicians only can also view it on web-DENIS.

When additional medications are placed in the program, we’ll update the forms list and alert providers through messages on web-DENIS.