Some drugs, typically those administered in a doctor's office, hospital setting, or infusion clinic, are facilitated through the medical benefit. Patients (our members) who receive drugs via infusion (rather than via a self-administrable injector picked up at a pharmacy) will likely receive those drugs through their medical benefit plan.
When your patients (our members) use their medical benefit prescription drug plan, it's important to determine what's covered by their plan and what guidelines, if any, apply to those drugs. Our medical benefit is designed to provide members with safe and affordable access to covered medications.
What providers need to know:
- How to determine what prescription drugs are covered by a member's plan
- If additional approval is needed from the health plan before a member receives prescription drugs
- Dosage and Frequency Guidelines applying to some prescription drugs
- Coverage requests for medications not covered under our medical benefit guidelines
- Members have a right to appeal a coverage decision. To find out if a medical benefit drug is covered by a member's plan, visit the Provider Engagement, Analytics & Reporting (PEAR) portal, or call 1-800-ASK-BLUE.
Precertification
Precertification means that a doctor must obtain approval from your health plan for coverage of, or payment for, your medication. Independence Blue Cross (IBX) requires prior authorization of certain covered drugs to confirm that the drug prescribed is medically necessary, clinically appropriate, and is being prescribed according to FDA approved labeled or medically accepted use.
Some examples of drugs that require precertification are drugs to treat conditions like hemophilia, cancer, and multiple sclerosis. IBX nurses and physicians evaluate requests for these drugs based on medical policy and clinical information submitted by your prescribing doctor. Their evaluation may include a review of potential drug interactions or contraindications, appropriate dosing and length of therapy, as well as utilization of other drug therapies, if necessary.
For services or drugs that require precertification, please log into the PEAR portal, visit our website, IBX.com, or call 1-800-ASK-BLUE and follow the prompts for authorizations. For more information on the list of specialty drugs requiring precertification, review our Precertification and cost-share requirements.
Medical policy
You can access medical policies through our Medical and Claim Payment Policy Portal. To view a specific policy, select Commercial or Medicare Advantage in the search field and type the drug name.
Step therapy
IBX performs utilization review of step therapy for certain drugs. Step therapy requires a member to first try certain drugs (sometimes referred to as “preferred products") to treat a member's medical condition before the plan will cover another drug (sometimes called a “nonpreferred product") for that condition.
For example, if Drug A and Drug B both treat your medical condition, IBX may not cover Drug B unless a member tries Drug A first. If Drug A does not work for a member, IBX will then cover Drug B.
Dosage and frequency limits
IBX provides coverage for your patients (our members) in accordance with the medical necessity criteria in our policies and the terms of each member's benefit contract. Through the Dosage and Frequency Program, IBX reviews the requested dosage and frequency of certain specialty drugs that are eligible for coverage under the medical benefit to ensure that these regimens adhere to safe prescribing limits.
Coverage of the drugs in the Dosage and Frequency Program is contingent upon review for medical necessity and appropriate dosage and frequency. This review is conducted as part of the precertification process for all members enrolled in IBX medical plans.
Dosing and Frequency Guidelines can be found in the Medical and Claim Payment Policy Portal. Additional information about this program is available on the Dosage and Frequency page of our website.
Most Cost-Effective Setting (MCES)
IBX wants your patients (our members) to receive treatment in accordance with the coverage criteria in our medical policies and in settings that are both safe and cost-effective. Through the Most Cost-effective Setting Program, IBX reviews the requested treatment settings for certain specialty drugs that are eligible for coverage under the medical benefit. This review is conducted as part of the precertification process for your patients (our members) enrolled in IBX commercial medical plans.
For the drugs in this program, IBX considers the following settings to be safe and cost-effective:
- A physician's office
- The member's home, where the drug is administered by an in-network home infusion provider
- An ambulatory (freestanding), independent infusion suite
View the complete list of drugs eligible through the MCES program.
How to submit a precertification request
Participating providers are required to be registered with the PEAR portal and should submit requests electronically through PEAR Practice Management (PM) for services to be rendered at an acute care facility, ambulatory surgical center, or office setting.
IBX Utilization Management will review the precertification request. If a nurse cannot approve the request based on established criteria, a medical director will review the request.
If approved, the requesting doctor will be notified of approval via the PEAR portal or telephone, and the claims system will be coded with the approval. Note: PEAR portal approval can occur in real time, which means a member can be approved for the drug prior to leaving the provider's office.
A member can call 1-800-ASK-BLUE to determine if the request is approved. If denied, the requesting provider will be notified via telephone and letter. Members are also notified of all determinations, approvals, and denials via letter. The appeals process will also be detailed in the denial letter.
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