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

MDR Changes effective 7/01/2021

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

Summary

BCBSRI is making significant Medical Drug Review (MDR) changes effective July and August 2021. Five drugs are being added to prior authorization requirements (effective 8/1/2021), nine drugs are having prior authorization removed, and 14 drugs are getting updated step therapy requirements where patients must try and fail specific alternative medications first.

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What to do

by Jul 1, 2021 · 5 steps
01Update billing system to reflect new step therapy requirements for eye injection drugs (Eylea, Lucentis, Beovu) and cancer support medications (Nyvepria, Fulphila, Ziextenzo) - patients must try Avastin/Mvasi/Zirabev or Neulasta/Udenyca first.
02By August 1, 2021: Add prior authorization requirements for iron infusions (Feraheme, Injectafer, Monoferric), hormone therapy (Histrelin, triptorelin), and update step therapy for biosimilar medications.
03Remove prior authorization from nine medications including Granix, Zarxio, Neulasta, and several cancer biosimilars.
04Contact Prime Therapeutics for all prior authorization requests.
05Claims will be denied without proper prior authorization or step therapy documentation.

Codes mentioned

Q0138J1439J1437J9226J3316J1453J1447Q5101Q5117Q5116J2505Q5111Q5107Q5118

Original notice

MDR Changes effective 7/01/2021
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 8/01/2021HighEffective Aug 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 changesOncologyHematologyOphthalmologyEndocrinologyNephrologyGastroenterologyCode Q0138Code J1439Code J1437Code J9226Code J3316Code J1453Code J1447Code Q5101Code Q5117Code Q5116Code J2505Code Q5111Code Q5107Code Q5118

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