Precertification program expands for medical specialty drugs
Specialty drugs are one of the key drivers of increasing health care costs today, with costs expected to continue their upward trend in the coming years1. These specialty drugs are expensive and used to treat rare and complicated conditions like hepatitis C, rheumatoid arthritis, multiple sclerosis, hemophilia and cancer.
Some specialty drug treatments can be taken orally, which members can manage themselves. Others need to be infused, which requires a professional to administer. Because of this, these drugs may be covered under a health plan’s pharmacy or medical benefit. To help control costs and achieve the best outcome, it is important to have a specialty drug management strategy in place under both the pharmacy and medical benefits.
As part of our ongoing efforts to manage these drug costs, we are expanding our precertification program to include medical specialty edits. The expansion of our precertification program will allow clients who currently have our precertification program to benefit from these enhancements. There are two components to this expansion:
Coverage for select clinically equivalent agents over others where applicable:
- Covering better value agents that are clinically equivalent helps manage the overall cost of care and continues to promote evidence-based medicine.
- Available on June 1, 2017 for:
- Individual, fully insured and ASO (Administrative Services Only) clients who have our precertification program managed by AIM
- ASO clients in California who have our precertification program managed by Anthem
Dose, frequency and duration for certain agents, including drugs:
- Coverage for safe and effective dosing and drug administration for the member
- Available beginning September 1, 2017 for: Individual, fully insured and ASO clients who have our precertification program managed by AIM
Expansion of our precertification program allows us to manage medical specialty drugs using the same strategies employed under the pharmacy benefit. This results in consistent, comprehensive clinical reviews.
Applies to California: Large Group, Small Group, Individual (Under 65)
Contact your sales representative with questions.