Provider Remittance Advices
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P F
Jun 1, 2021

MDR Changes effective 7/01/2021

As part of our ongoing efforts to make high-quality and affordable healthcare available to our members, BCBSRI regularly reviews the list of prescription drugs we cover under our medical benefit. Our goal is to make sure that our members continue to have access to effective medications at the lowest possible cost. As a result, the following changes are being made to the Medical Drug Review (MDR) program. Existing and new prior authorization reviews will continue to be handled by our pharmacy benefits manager, Prime Therapeutics.

Code
Drug Name
Prior Authorization
ADD/REMOVE
Commercial
Effective Date of Change
Medicare
Effective Date of Change
Q0138
Feraheme
ADD
8/1/2021
N/A: No PA
J1439
Injectafer
ADD
8/1/2021
N/A: No PA
J1437
Monoferric
ADD
8/1/2021
N/A: No PA
J9226
Histrelin implant
ADD
8/1/2021
N/A: No PA
J3316
triptorelin
ADD
8/1/2021
N/A: No PA
J1453
Fosaprepitant (Emend)
REMOVE
2/1/2021
N/A: No PA
J1447
Granix
REMOVE
8/1/2021
8/1/2021
Q5101
Zarxio
REMOVE
8/1/2021
8/1/2021
Q5117
Kanjinti
REMOVE
8/1/2021
N/A: No PA
Q5116
Trazimera
REMOVE
8/1/2021
N/A: No PA
J2505
Neulasta
REMOVE
8/1/2021
8/1/2021
Q5111
Udenyca
REMOVE
8/1/2021
8/1/2021
Q5107
Mvasi
REMOVE
8/1/2021
N/A: No PA
Q5118
Zirabev
REMOVE
8/1/2021
N/A: No PA

 

Additionally, for our Commercial line of business, prior authorization criteria updates are being made to the following medical drugs effective July and August. The following medical drugs will require documented trial and failure of alternative medical drugs as noted below.

Medical Drug
Prior Authorization Criteria Update
Effective Date
Inflectra
Will no longer require trial and failure of Remicade
8/1/2021
Avsola
Will no longer require trial and failure of Remicade
8/1/2021
Renflexis
Will require documentation of trial and failure of Remicade, Inflectra and Avsola
8/1/2021
Avastin (oncology)
Will require documentation of trial and failure of Mvasi and Zirabev
8/1/2021
Herceptin
Will require documentation of trial and failure of Kanjinti and Trazimera
8/1/2021
Rituxan
Will require documentation of trial and failure of Truxima and Riabni
8/1/2021
Eylea
Will require documentation of trial and failure of Avastin, Mvasi or Zirabev
7/1/2021
Lucentis
Will require documentation of trial and failure of Avastin, Mvasi or Zirabev
7/1/2021
Beovu
Will require documentation of trial and failure of Avastin, Mvasi or Zirabev
7/1/2021
Nyvepria
Will require documentation of trial and failure of Neulasta and Udenyca
7/1/2021
Fulphila
Will require documentation of trial and failure of Neulasta and Udenyca
7/1/2021
Ziextenzo
Will require documentation of trial and failure of Neulasta and Udenyca
7/1/2021
Neupogen
Will require documentation of trial and failure of Granix and Zarxio
8/1/2021
Nivestym
Will require documentation of trial and failure of Granix and Zarxio
8/1/2021
Feraheme (nondialysis)
Will require documentation of trial and failure of Ferlecit, INfeD and Venofer
8/1/2021
Injectafer (nondialysis)
Will require documentation of trial and failure of Ferlecit, INfeD and Venofer
8/1/2021
Monoferric (nondialysis)
Will require documentation of trial and failure of Ferlecit, INfeD and Venofer
8/1/2021