Posted in BCBS Empire NY, NY Providers, Pharmacy (Various Insurance Payers), Training, Updates

BCBS (NY): HIV medication combinations may require Prior Auth, 05/01/2021

Effective 05/01/21 and for the DOS thereafter, BCBS (Empire) NY, will implement a new prior authorization for HIV medications/drugs. This would help to ensure that the patients are not receiving therapeutic duplications when taking certain combinations.

In order for the Member to continue to receive the treatment that involves drug combinations, the provider must submit an authorization for EACH Drug and provide a MEDICAL NECESSITY rationale as to why that drug combination is clinically needed.

Combinations that are considered clinical duplicates are based on drug mechanism of action (MOA) and developed in accordance with the U.S. Department of Health and Human Services HIV Guidelines.

Examples of HIV drug combinations that would trigger duplicated drug combinations:

Providers and members expected to be impacted by this policy will receive advanced notice by mail.

Source: BCBS (NY) Providers Communications: March 2021



My name is Kate Patskovska, CPB. I am an Independent Medical Biller CPB (AAPC) and an owner of KR2 Medical Billing. KR2 Medical Billing is a full service Consulting/Medical Billing Business that is dedicated to educating, consulting, and overall improving the "financial health" of your medical practice.

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