April 29, 2022
Effective Aug. 1, 2022, we will begin recommending some preferred drugs over other drugs through our medical policies, when clinically appropriate, to improve access to more affordable care for our members. This will be for some of our commercial members.
What’s changing: When submitting a prior authorization request for some drugs you will receive a recommendation for comparable, clinically appropriate preferred drugs. This may also occur during the medical policy, pre-service review. The categories of drugs and medical policies include:
- Medical oncology drugs: see Medical Policy Oncology Medications RX502.061 for more information.
- Infliximab and biosimilars: see Medical Policy Infliximab and Associated Biosimilars RX501.051 for more information.
- Enzyme replacement therapies: see Medical Policy Enzyme-Replacement Therapy for Lysosomal Storage Disorders RX501.067 for more information.
- Osteoporosis therapies: see Denosumab (Prolia & Xgeva) RX501.140 Medical Policy on the Pending Policies page on our Medical Policies website for more information.
Refer to the BCBSMT Medical Policies, Utilization Management page and online PA code lists to determine if the drugs you are recommending require prior authorization and how to obtain prior authorization. If PA is needed it will be processed by BCBSMT or AIM Specialty Health®.
Failure to prescribe the drugs recommended through these enhanced PA programs could result in claim denial if an exception does not apply.
For More Information: Watch News and Updates for more information and future announcements.
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Checking eligibility and/or benefit information and/or obtaining prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. If you have any questions, call the number on the member's ID card.
AIM Specialty Health (AIM) is an independent company that has contracted with BCBSMT to provide utilization management services for members with coverage through BCBSMT.