Additional medical drugs to require prior authorization/clinical review effective July 1, 2015

Effective with dates of service on or after July 1, 2015, BCN will require prior authorization/clinical review for the medications listed below before these drugs will be covered under the members' medical benefits.

This requirement applies only to BCN HMO^SM (commercial) members. For BCN Advantage^SM members, no prior authorization/clinical review is required for these services.

These prior authorization/clinical review requirements apply only to members who start their medications on or after July 1, 2015. Members who have a paid claim for one of these medications by the end of June 2015 will not be required to seek initial prior authorization/clinical review.

Prior authorization/clinical review criteria include, but are not limited to: diagnosis, lab results, dosing and frequency of administration. We may also require documentation of medications previously used to treat the member's condition, including dosage, regimens, dates of therapy and response, as well as additional pertinent medical information.

To request prior authorization/clinical review for one of these medications, please submit the request through BCN's e-referral system or fax the request to BCN Care Management at 1-800-675-7278. You can also call Care Management at 1-800-392-2512.

As a reminder, all medications represented by codes J3490, J3590 also require prior authorization/clinical review for all members because these codes represent services that are not otherwise classified.

For a full list of all medications and procedure codes subject to prior authorization/clinical review requirements, click Clinical Review & Criteria Charts at the left on this page and then click Blue Care Network Referral and Clinical Review Program.

Additional information on the medical necessity criteria is available on the same Web page. Just scroll down to the medical necessity criteria section and click Clinical Information for Drugs Covered under the Medical Benefit That Require Medical Necessity Review.

Updated versions of these documents will be available on the Web by July 1.