Changes Coming to the Medical Drug Benefit Program
Act
by Jan 1, 2027
Effective date
Jan 1, 2027
Identified
Oct 15, 2026
Summary
Effective January 1, 2027, Blue Cross and Blue Shield of Texas will expand its Medical Drug Benefit Program to update coverage for specific prescription drugs administered by healthcare providers in clinical settings. This affects coverage determinations for therapeutic alternatives, newly FDA-approved drugs, FDA-accelerated approval drugs, and drugs with limited medical benefit coverage. The policy applies to commercial members only and does not affect Medicaid, HMO, Federal Employee Program, or Postal Employee Program members. Billing teams must verify eligibility and prior authorization requirements through Availity Essentials or preferred vendors before service delivery.
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01Billing and clinical teams must (1) review the Medical Drug Benefit Program Summary to identify which drugs fall under the expanded program; (2) verify eligibility and prior authorization requirements through Availity Essentials or preferred vendors before rendering services for any medical drugs administered in clinical settings; (3) update internal workflows to confirm whether prior authorization or exception requests are required before submitting claims; (4) familiarize staff with the Medical Drug Benefit Program exception form process for requesting coverage exceptions when medically necessary.
02Staff should reference prior authorization support materials and the digital lookup tool to determine if recommended drugs require prior authorization.
03Note: Checking eligibility and obtaining prior authorization does not guarantee payment; final coverage determination occurs upon claim receipt based on member eligibility and plan terms.
Original notice
Changes Coming to the Medical Drug Benefit Program
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