Reminder: New MA PPO prior authorization requirements for select specialty medications

What’s new?
Select specialty medications covered under the Medicare Part B medical benefit will require prior authorization, starting July 5, 2017. These are medications that aren’t self-administered, but must be administered via injection or infusion by a doctor or health care professional in the office setting.

The purpose of these new requirements is to help ensure that health care providers use the most effective therapies available, in keeping with the Centers of Medicare & Medicaid Services coverage guidelines for medical necessity, safety and efficacy.

Providers must obtain prior authorization and verify patient benefits to be eligible for payment for administering these medications. If a prior authorization isn’t obtained before services are rendered, the claim will be rejected. Also, providers may not bill members for services that required, but didn’t receive, preapproval.

Keep in mind that authorization isn’t a guarantee of payment. CMS benefit coverage rules and benefit exclusions or limitations will apply.

Which specialty medications will require prior authorization?
Below is a sampling of specialty drugs that will require Medicare Part B prior authorization:

We’ll evaluate the program on an ongoing basis, and may add or remove new drugs or procedures from the prior authorization list. When this happens, we’ll notify you via The Record or web-DENIS.

Beginning July 5, you can find a list of medications that will require a prior authorization on the Medicare Advantage PPO medical drug policies and forms page. Or from Provider Secured Services, click on Medicare Advantage PPO Medical Benefit – Medication Prior Authorization.

How do I initiate a prior authorization request?
Prior authorization requests can be submitted through the NovoLogix^® online tool. NovoLogix allows providers to obtain real-time status checks on prior authorizations and immediate approvals for certain medications when patients meet specific criteria. Use of the NovoLogix tool will save time and lessen your administrative burden by eliminating the manual process of submitting a form.

Submit prior authorization requests by following these steps:

• Log in to Provider Secured Services
• Click on Medicare Advantage PPO Medical Benefit – Medication Prior Authorization.
• Follow the instructions.

If you can’t access Provider Secured Services or aren’t registered to use NovoLogix, call 1-877-258-3932 Monday through Friday from 8 a.m. to 8 p.m. Eastern time.

If you have any questions about this process, call the Pharmacy Clinical Help Desk at 1-800-437-3803.

How do I request access to NovoLogix?

• If you already use Provider Secured Services, fill out Addendum P and fax the form to us at 1-800-495-0812.
• If your office or facility has never used Provider Secured Services, learn how at bcbsm.com/providers. When completing the application, be sure to check “Medical Drug PA” in Section 6.
• If you can’t access Provider Secured Services, call 1-877-258-3932 Monday through Friday from 8 a.m. to 8 p.m. Eastern time.

Want more information

• You can find a drug list, NovoLogix user guide, NovoLogix tutorial video and FAQ document from Provider Secured Services. Click on Medicare Advantage PPO Medical Benefit – Medication Prior Authorization.

• You can also find our medical policies and request forms in the Provider Toolkit for Medicare Advantage PPO. Click on Medicare Advantage PPO medical drug policies and forms.