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Volume 7, Issue 2 • January 16, 2013

► Blue Alert

Blues now require prior authorization of certain physician-administered specialty drugs

Blue Cross Blue Shield of Michigan will soon require prior authorization of 13 specialty drugs in order for the therapies to be covered under members’ medical benefits.

Briefly ...

These types of specialty drug claims now total more than $300 million a year at BCBSM, and we expect that to increase by 15 to 20 percent annually due to the rapid increase of specialty drugs coming to market.

The selected specialty drugs require administration by a physician or other health care professional. Members must not administer the drugs themselves or obtain them at a pharmacy with their pharmacy benefits.

The change is effective Jan. 22.

The Blues are adding 12 drugs to the prior authorization program to respond to customer concerns about appropriate utilization and potential safety issues of high-cost specialty drugs. It’s part of our approach to help contain our customers’ future drug costs.

These types of drug claims now total more than $300 million a year at BCBSM, and we expect that to increase by 15 to 20 percent annually due to the rapid increase of specialty drugs coming to market. Specialty drugs make up 1 percent of the drugs prescribed for BCBSM members, but represent 20 percent of the total drug cost.

Prior authorization requirements for the drugs will apply for members of all groups. The requirements apply regardless of whether members receive treatment in Michigan or out of state, because these medications are covered under Blues medical, not pharmacy, benefits. If you have an ASC customer that would like to opt out of the program, be sure to submit an ASC plan modification request.

The program is designed to ensure that specialty medications administered by health care professionals in the office, home or infusion setting are prescribed and given appropriately. There will be no impact to specialty drugs administered by health care professionals in an inpatient or outpatient hospital setting.

Physicians will be responsible for requesting prior authorization of the medications. If authorization isn’t requested or is denied, members will be liable for the cost of any services delivered, though therapy may be authorized after the fact. BCBSM will notify both physicians and members of these determinations and explain the member appeals process for rejected requests and denied claims. A physician may appeal on a member’s behalf.

NOTE: This program in no way affects BCBSM pharmacy benefits. It also doesn’t apply to Blue Care Network members.

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

The prior authorization requirement is already in place for use of Makena, a drug used to prevent preterm labor. The Blues will continue to expand the program to include more specialty drugs. The 13 drugs included Jan. 22 are:

Specialty Medication Requiring Prior Authorization Condition Treated Grandfathered Renewal Preauthorization Required Starting
Abatacept (Orencia®) Rheumatoid arthritis Yes July 1, 2013
Belimumab (Benlysta®) Lupus Yes July 1, 2013
Tocilizumab (Actema®) Rheumatoid arthritis Yes July 1, 2013
Ustekinumab (Stelara®) Plaque psoriasis Yes July 1, 2013
Denosumab (Xgeva®) Bone loss Yes Sept. 1 , 2013
Denosumab (Prolia®) Bone loss Yes Sept. 1 , 2013
Onabotulinumtoxin A (Botox®) Various reasons No  
Abobotulinumtoxin A (Dysport®) Various reasons No  
Rimabotulinumtoxin B (Myobloc®) Various reasons No  
Incobotulinumtoxin A (Xeomin®) Various reasons No  
Collagenase (Xiaflex®) Finger contractures No  
Corticotropin (Acthar HP® gel) Infantile spasms No  
Hydroxyprogesterone caproate (Makena) Preterm labor No  

Prior authorization is a clinical review process that ensures appropriate use of medications while improving safety and cost-effectiveness. It is not a guarantee of coverage. The member must have benefit coverage for the drug. Health care providers will follow their usual processes to verify member benefits and eligibility.

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