This article is for prescribers caring for our members
A new law1 takes effect October 1 that’s focused on health insurers’ medication step therapy protocols. These protocols establish the specific sequence in which a prescription medication for a specified condition is covered by health insurance as part of a utilization management program.
For Blue Cross to cover a medication, a member may be required to try a less expensive, but equally effective, option (lower step medication) before we’ll cover the higher step medication that the prescriber has requested. If the lower step alternative(s) is not clinically appropriate, we’ll review exception requests.
What you need to know
Here’s how Blue Cross is complying with the requirements of the law:
- It applies to fully insured members.
- Members can request their own exception and ask Blue Cross to cover the prescription for the higher step medication.
- We’ll reach out to you, the prescriber, and ask for additional clinical information to support the member’s request in this situation.
- Prescribers can request a coverage exception, as always, if you believe the lower step alternative(s) is not clinically appropriate. We encourage you to provide us with clinical notes to show:
- Previous history of using one of the following:
- The lower step medication; or
- Another medication in the same pharmacologic class; or
- Another medication with the same mechanism of action.
- Clinical reasons why the lower step alternative is not clinically appropriate for the member. These may include:
- They are stable on the higher step medication.
- Switching would cause an adverse reaction or physical or mental harm.
Supporting documentation
- Clinical notes or supporting clinical statements.
- Name and strength of alternative tried and failed (if alternatives were tried) and specifics of treatment failure (if applicable).
- References from peer reviewed journals, nationally recognized compendia, or consensus documents/sanctioned guidelines.
Thank you
We appreciate you responding to requests for additional clinical information.
Questions?
Contact Pharmacy Operations at 1-800-366-7778.
1. MGL Chapter 176O, Section 12A and B.
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