12/08/2023
Blue Cross and Blue Shield of Texas (BCBSTX) is committed to providing its members access to safe, appropriate, and cost-effective health care within their plan benefits. To ensure the appropriate use of GLP-1s as indicated for diabetes, we are making it easier for providers to bypass our prior authorization (PA) process for some of our members with diabetes.
What this means: In June 2023, we implemented ‘smart’ automation technology at the pharmacy counter to assist with PA review requirements for GLP-1 drugs covered by the pharmacy benefit. The technology reviews documented medical diagnosis of Type 2 diabetes and claims history for other diabetes medications like insulin. When applicable members have a pharmacy claim for a GLP-1 diabetes drug and BCBSTX has documentation of both the Type 2 diabetes diagnosis and claims history for other diabetes medications, members are flagged as having met the PA criteria and a PA request is not needed. The applicable members only need a prescription for their medicine. Medical chart notes are only required in cases where we do not have a member’s diabetes diagnosis and other diabetes medication history on file.
What’s changing: Beginning Jan. 1, 2024, applicable commercial plan members using a GLP-1 diabetes drug who do not have a diabetes diagnosis and other diabetes medication history on file will be required to go through the PA process. This will apply to both group members with prescription drug benefits administered by Prime Therapeutics and members who purchase individual and family plans, who have the PA program as part of their pharmacy benefits.
- If your patient does not have a Type 2 diabetes diagnosis in their medical claims history and prescription history for other diabetes drugs, you may need to submit documentation of the missing information to meet the new PA criteria. Coverage of a GLP-1 diabetes drug may not be approved without documentation of a diabetes diagnosis.
- Note: If your patient has an existing PA approval for a GLP-1 diabetes drug, the PA will remain in effect until the expiration date stated on the PA approval notice. You, or your patients, may receive a PA notification alert to re-submit the request in advance as part of our notification process.
Starting in 2024, Medicare members will also need PA approval for GLP-1 coverage consideration to treat Type 2 diabetes. If a diagnosis of Type 2 diabetes is already on file with us, this request may not be needed.
What’s next: BCBSTX and Prime Therapeutics continue to monitor market changes and pharmacy dispensing and medication utilization. Pharmacy clinical management strategies will be adjusted as needed to best support our members while managing the total cost of care.