Specialty Drug Medical Benefit Management. Note! Contents are subject to change and are not a guarantee of payment.

Transcription

1 Specialty Drug Medical Benefit Management Note! Contents are subject to change and are not a guarantee of payment.

2 Agenda Introduction Specialty Medical Benefit Management (SMBM) Strategy Authorization Process Other Important Information Provider Tools Provider Relations Contact Information 2

3 Introduction Specialty Drug Medical Benefit Management Drug costs continue to rise and specialty drugs contribute significantly to that trend. We have been managing specialty drugs under the pharmacy benefit for years through: Prior authorizations Preferred drug strategies Drug exclusions 3

4 Introduction Specialty Drug Medical Benefit Management We are adopting some of the practices to manage specialty drugs billed under the medical benefit when the specialty drug is administered in: An outpatient hospital Infusion suite Physician office The patient s home 4

5 Agenda Introduction Specialty Medical Benefit Management (SMBM) Strategy Authorization Process Other Important Information Provider Tools Provider Relations Contact Information 5

6 SMBM Strategy Specialty Medical Benefit Management (SMBM) Strategy Three components: 1. National Drug Code (NDC) required and validated 2. Self-administered specialty drugs blocked under medical 3. Prior authorization required for certain specialty drugs billed under the medical benefit 6

7 SMBM Strategy NDC Information In 2015, BlueCross BlueShield of South Carolina (BlueCross) and BlueChoice HealthPlan (BlueChoice) began requesting that NDC codes be added to all medical claims filed for drugs. In 2016, this has become a requirement. We will reject claims for drugs that do not include a valid NDC code. 7

8 SMBM Strategy Self-administered Drug Block Certain self-administered drugs the medical benefit covered will now only be covered under the pharmacy benefit. This change will affect some members out-of-pocket costs. We require most of our members to have CVS/specialty fill their prescriptions for specialty drugs when the pharmacy benefit covers them. CVS/specialty is a division of CVS Health, an independent company that provides pharmacy services on behalf of our health plans. 8

9 SMBM Strategy Prior Authorizations We will require prior authorization for certain medical specialty drugs billed under the medical benefit. BlueChoice has been requiring prior authorizations for some of these specialty drugs for many years. Beginning June 1, 2016, CVS/caremark, using its NovoLogix medical prior authorization system, will perform prior authorization reviews for drugs billed under the medical benefit. Providers prescribing pharmacy specialty drugs billed under the pharmacy benefit will continue to request required prior authorizations, as usual, through CVS/caremark. 9

10 SMBM Strategy Prior Authorization Requests If the request is made: Before June 1, 2016, submit the request as usual. On or after June 1, 2016, submit the request via NovoLogix. 10

11 SMBM Strategy Participating Plans BlueCross and BlueChoice Plans: Fully insured Exchange plans BlueChoice self-funded plans 11

12 SMBM Strategy Nonparticipating Plans BlueCross and BlueChoice plans not participating with the program include: Federal Employees Program (FEP) State Health Plan Out-of-state members (BlueCard ) Groups that carve out pharmacy BlueCross self-funded plans will begin participating January 1,

13 Agenda Introduction Specialty Medical Benefit Management (SMBM) Strategy Authorization Process Other Important Information Provider Tools Provider Relations Contact Information 13

14 Authorization Process Provider Online via Single Sign-on through My Insurance Manager SM or NovoLogix phone NovoLogix Clinical Review* Claims are Paid Services are Performed Approval/Denial of Request 14 * If not auto-approved, NovoLogix makes determinations within two days for most requests

15 Authorization Process Step 1: Gather necessary patient and therapy information GENERAL CLINICAL INFORMATION PROTOCOLS/NOTES Name and NPI of provider delivering the drug Member name and ID number Place of service that will perform the procedures Anticipated dates of service Primary diagnosis Authorization priority NDC code Quantity Complete any applicable protocol questions to complete the authorization request After creation you will be able to add Notes and/or upload supporting documentation NovoLogix may need additional information to complete the authorization request. Those requests will show in the Provider Action section of your homepage. 15

16 Authorization Process Prior Authorization Request Example Place of Service Date(s) of Service NDC and Quantity (*) Indicates required fields 16

17 Authorization Process How to Submit Authorization Requests Initiate requests using My Insurance Manager (via or the preferred method: 1. Identify patient, physician and treatment facility 2. Complete the online authorization request form 3. Answer protocol questions, if applicable 4. Confirm the information 5. Submit the request 17

18 Authorization Process Prior Authorization Review 1 Intake Level 2 Initial Review 3 Requests are evaluated using NovoLogix s clinical algorithm At this point, authorizations can: 1. Approve 2. Deny Additional Clinical Review Requests can: 1. Approve 2. Require additional clinical review 3. Pend for clinical validation of medical records NovoLogix will review request and can: 1. Approve 2. Send on for additional clinical review 3. Deny A peer-to-peer discussion is always available! Note: Refer to your authorization number for updated information regarding the submitted request. 18

19 Authorization Process Notification of Determination Written and electronic provider notification Member will receive a separate notification 19

20 Authorization Process Notification of Determination Approval Notification Electronic and written notice to provider and member. Provider can view approval on NovoLogix tool. Denial Notification Electronic and written notice to ordering physician. Member will receive written notice. Authorization Validity Period Most drug authorizations are good for one year from approval date. Provider Reconsideration Review Instructions Instructions are included in written communications. BlueCross will handle the reviews. 20

21 Authorization Process Retrospective Review Process Within 30 calendar days of date of service, NovoLogix will review requests based on medical necessity. Authorization determinations are listed in the provider s queue. 21

22 Authorization Process Additional Clinical Information Authorizations requiring additional information will be in the Provider Action queue. Provide the clinical information as quickly as possible for a timely determination. 22

23 Agenda Introduction Specialty Medical Benefit Management (SMBM) Strategy Authorization Process Other Important Information Provider Tools Provider Relations Contact Information 23

24 Other Important Information Claims Process Claim Submission Submit claims to BlueCross and BlueChoice. File claims using Electronic Media Claims (EMC) or online using My Insurance Manager available at or Check claim status through My Insurance Manager. Provider Reconsideration Review Process Submit Provider Reconsideration Review requests to BlueCross for review of prior authorization or claim payment denials. Follow the instructions on the non-authorization letter or remittance notification. 24

25 Agenda Introduction Specialty Medical Benefit Management (SMBM) Strategy Authorization Process Other Important Information Provider Tools Provider Relations Contact Information 25

26 Provider Tools My Insurance Manager Available 24 hours a day, seven days a week Check patient eligibility and if drug requires prior authorization Single sign-on to NovoLogix to complete the authorization Upload additional clinical information 26

27 Provider Tools Other Resources NovoLogix provider training video Copy this URL to your browser:» dia/b61694b e2d503a76 Coming soon! NovoLogix system Q& A session Guide: What You Need to Know About Medical Specialty Drug Prior Authorizations Drug Lists on our websites» Medical specialty drugs» Self-administered drugs 27

28 Agenda Introduction Specialty Medical Benefit Management (SMBM) Strategy Authorization Process Other Important Information Provider Tools Provider Relations Contact Information 28

29 Provider Relations Contact Information NovoLogix Help: Available Monday - Friday, 7 a.m. to 6 p.m. Central Time Call: helpdesk@novologix.net BlueCross and BlueChoice Provider Relations and Education: Phone: Provider.Education@bcbssc.com 29

30 SMBM Strategy Questions? Send to: Subject: Webinar - SMBM 30

31 How Do I Submit a Prior Authorization? Questions? Log on to My Insurance Manager, then go to Patient Care and select Precertification/Referral. Answer the two highlighted questions by selecting Specialty Drugs, then click Continue. A message may appear advising that preauthorization is required. You may call or click the link to initiate the request. 31

32 Questions? Where Will the Medical Specialty Drugs and Selfadministered Drugs Lists be Located? The drug lists will be available on our websites, or in the Precertification and Pharmacy sections on the Provider page. How Do I Check the Status of a Prior Authorization? Go through My Insurance Manager to verify the status of a prior authorization on the NovoLogix system. 32

33 SMBM Strategy 33