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 (PA) request for certain drugs, you will receive a recommendation for comparable, clinically appropriate preferred drugs. This may also occur during the medical policy, pre-service review. Below are categories of drugs and applicable Blue Cross and Blue Shield of Texas (BCBSTX) medical policies for more information:
- Medical Oncology drugs: see Medical Policy Oncology Medications RX502.061.
- Osteoporosis therapies: see Medical Policy Denosumab (Prolia & Xgeva) RX501.140.
- Infliximab and biosimilars: see April 1 Medical Policy Infliximab and Associated Biosimilars RX501.051.
- Enzyme replacement therapies: see April 1 Medical Policy Enzyme-Replacement Therapy for Lysosomal Storage Disorders RX501.067.
Refer to the BCBSTX Medical Policy and our Utilization Management page 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 BCBSTX Medical Management 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 BCBSTX to provide utilization management services for members with coverage through BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by third party vendors.