Continuation of Drug Therapy

Policy ID: I-9100-002

Section: Injections

Effective Date: October 01, 2021

Last Reviewed: September 12, 2023

Applies To: Commercial and Medicaid Expansion

Description

Blue Cross Blue Shield of North Dakota (BCBSND) does not recognize the use of prescription drug samples, manufacturer provided drugs, or administration of a drug after a denied precertification request as acceptable criteria for approving continued use of a requested drug.

Criteria

Coverage is subject to the specific terms of the member’s benefit plan.

Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.

If an individual is started on samples of a requested drug, the requested drug is manufacturer provided, or the requested drug was administered after a denied precertification request, this is not considered medically necessary and appropriate criteria to approve an individual for the continued use of a requested drug.

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-21-2021 - Effective October 01, 2021

Adopted policy

Internal Medical Policy Committee 9-28-2022 Annual review, no clinical content change

Internal Medical Policy Committee 9-12-2023 Annual review, no clinical content change

Links

Not Applicable

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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Continuation of Drug Therapy

Description

Criteria

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer