Preferred Drug Strategy for Medical Benefit Drugs with Therapeutic Equivalents or Alternatives To Be Covered Through Enhanced Prior Authorization
AI Summary
Blue Cross Blue Shield of Texas is implementing enhanced prior authorization for certain medical benefit drugs (including Infliximab, Pegfilgrastim, Rituximab, and Trastuzumab biosimilars) administered in clinical settings. When submitting prior authorization requests for non-preferred drugs, providers will receive a list of preferred therapeutic equivalents or alternatives that must be considered first.
Action Required
Before January 1, 2026: Review Medical Policy numbers RX501.051, RX502.061, and RX502.030 for specific drug requirements. Update prior authorization workflow to include checking the Medical Benefit Therapeutic Alternatives Summary before submitting requests. Train clinical staff to consider preferred therapeutic equivalents for Infliximab, Pegfilgrastim, Rituximab, and Trastuzumab biosimilars. Always verify eligibility through Availity Essentials prior to drug administration to confirm prior authorization requirements.
Plan Types
Commercial
States
TX
Specialties
oncology, rheumatology, gastroenterology, hematology