Wiki Management of Preferred Drugs/Step Therapy

[JC052382]

Hi All!

I'm looking for some insight on what other Oncology practices are doing to manage preferred drugs/step therapy. We are finding this to be a struggle with our current staff and workload. Our biggest struggle seems to be with Anthem BCBS. We are frequently told no authorization is require for out of state plans. They then request medical records for review. We are seeing a lot of responses come back stating we didn't use their preferred product. It appears policies are different depending on the state in which the plan is from and we should be referring that state policy regardless of the state the service took place.

This is happening more frequently so I thought I would see what others are doing to manage this.

Anyone else experiencing this issue?

 

[rachaelwilleford]

I literally have a spreadsheet that I update monthly/quarterly. UHC typically updates their policies quarterly. Humana, Aetna has updates quarterly. The BCBS plans update when they want to. At the beginning of every month, I go through the websites and update our oncology/infusion billing staff on updates - this includes step therapy, site of care policies, and specialty medication restrictions, as well as reimbursement policies. I also include pharmacy because they really should be aware as well.

When it comes to BCBS, yes you have to refer to the home plan of the policy not the state home plan in which the provider is located. It's because the home plan sends the claim to the plan of the patient. Their medical and drug policies are the logic used to process the claim.