Preferred Drugs to be Recommended Through Enhanced Prior Authorization

 

11/25/2024

Effective Jan. 1, 2025, we will recommend some preferred drugs over other drugs according to our medical policies, when clinically appropriate. This will improve access to more affordable care for some of our commercial and individual members.

What’s changing? When submitting a prior authorization request for certain drugs, you will receive a recommendation for preferred drugs that are comparable and clinically appropriate. Blue Cross and Blue Shield of Texas or Carelon Medical Benefits Management will process these prior authorization requests.

Before submitting a prior authorization request, you can learn which drugs are included in this process, and what preferred drugs will be recommended, by referring to our medical policies. (List of drugs subject to change.)

  • For Pegfilgrastim and biosimilars, see Medical Policy number RX501.134, “Oncologic Uses of White Blood Cell Colony Stimulating Factors,” for more information (medical policy disclosed Oct. 1, 2024).
  • For immunoglobulin therapy, see Medical Policy number RX504.003, “Immunoglobulin (Ig) Therapy (Including Intravenous [IVIG] and Subcutaneous Ig [SCIG]),” for more information (medical policy disclosed Oct. 1, 2024).
  • For Rituximab and biosimilars, see Medical Policy number RX502.030, “Rituximab and Biosimilars for Non-Oncologic Indications,” (medical policy disclosed Oct. 1, 2024).

Always check eligibility and benefits first to confirm membership and other important information, including prior authorization requirements and utilization management vendors, if applicable.

For more details on prior authorization

 

Medical policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. Providers are encouraged to exercise their own clinical judgment based on each individual patient’s health care needs. The fact that a service or treatment is described in a medical policy is not a guarantee that the service or treatment is a covered benefit under a health benefit plan. Some benefit plans administered by BCBSTX, such as some self-funded employer plans or governmental plans, may not utilize medical policies. Members should contact the number on their member ID card for more specific coverage information.  

Please note that checking of eligibility and benefits information, and/or the fact that any pre-service review has been conducted, 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 applicable on the date services were rendered.

Carelon Medical Benefits Management is an independent company that has contracted with BCBSTX to provide utilization management services for members with coverage through BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding third party vendors.