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Blue Cross Blue Shield of Rhode IslandCommercial · Prior Auth · Physician / Facility · RI · Oncology, Hematology, Nephrology +3 moreHigh impact

MDR Changes effective 8/01/2021

Act
by Aug 1, 2021
Effective date
Aug 1, 2021
Identified
Jun 19, 2026

Summary

BCBS Rhode Island updated their Medical Drug Review (MDR) program effective 8/1/2021, adding prior authorization requirements for 5 injectable drugs and removing prior auth for 9 drugs. Additionally, brand-name drugs now require documented trial and failure of specific biosimilar alternatives before approval.

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What to do

by Aug 1, 2021 · 4 steps
01Billing team must update prior authorization workflows to obtain approval for Feraheme (Q0138), Injectafer (J1439), Monoferric (J1437), Histrelin implant (J9226), and triptorelin (J3316) for Commercial plans.
02Remove prior auth requirements for Granix (J1447), Zarxio (Q5101), Kanjinti (Q5117), Trazimera (Q5116), Neulasta (J2505), Udenyca (Q5111), Mvasi (Q5107), and Zirabev (Q5118).
03Update billing system to require documentation of biosimilar trial and failure before using brand-name alternatives.
04Claims without proper prior authorization or documentation will be denied.

Codes mentioned

Q0138J1439J1437J9226J3316J1453J1447Q5101Q5117Q5116J2505Q5111Q5107Q5118

Original notice

MDR Changes effective 8/01/2021
bcbsri.com · Always check the source before changing claims.
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Related changes

See all Blue Cross Blue Shield of Rhode Island changes →
MDR Changes effective 7/01/2021HighEffective Jul 1, 2021 · Physician / FacilityAdditional CPT and HCPCS Level II code changesMediumEffective Oct 1, 2019 · Physician / FacilityCPT® and HCPCS Level II code changesHighEffective Jan 1, 2019 · Physician / FacilityChanges being made to the Medical Drug Review (MDR) programMediumEffective Apr 1, 2022 · Physician / FacilityBrowse every Blue Cross Blue Shield of Rhode Island change in the policy list

Related policy hubs

Blue Cross Blue Shield of Rhode Island policiesRI policy changesOncologyHematologyNephrologyGastroenterologyEndocrinologyOB-GYNCode Q0138Code J1439Code J1437Code J9226Code J3316Code J1453Code J1447Code Q5101Code Q5117Code Q5116Code J2505Code Q5111Code Q5107Code Q5118

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