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ph-1087

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Coverage Exception Program Summary

Policy Number: PH-1087

This program applies to Blue Partner, Commercial, NetResults A series, SourceRx and Health Insurance Marketplace formularies.

Coverage Exception Criteria

These criteria apply to any request for medication that is not included on the covered drug list (formulary) and can be used to treat a medical condition/disease state that is not otherwise excluded from coverage under the pharmacy benefit.

If the request is for a medication and disease state/medical condition that is addressed with current clinical review criteria that criteria set will be applied.

EXCEPTION CRITERIA FOR APPROVAL

The requested medication will be approved when ALL of the following are met:

  1. The requested agent is not a drug/drug class/medical condition that is excluded from coverage on the pharmacy benefit

AND

  1. ONE of the following:
    1. The requested agent is not a drug/drug class/medical condition that is restricted to coverage under the medical benefit

OR

  1. The requested agent is appropriate for self-administration according to patient factors as determined by the provider

AND

  1. If the requested agent has additional clinical review criteria (e.g., prior authorization), the patient has met the additional clinical review criteria

AND

  1. The patient has an FDA labeled indication, or an indication supported in AHFS, DrugDex with 1 or 2a level of evidence, or NCCN with 1 or 2a level of evidence for the requested agent

AND

  1. ONE of the following:
    1. The requested agent has formulary alternatives for the diagnosis being treated by the requested agent AND ONE of the following:
      1. The patient has tried and had an inadequate response to at least two formulary alternatives, if available, for the diagnosis being treated with the requested agent

OR

    1. The prescriber has provided information stating that ALL available formulary alternatives are contraindicated, likely to be less effective, or cause an adverse reaction or other harm for the patienOR
  2. The requested agent does not have formulary alternatives for the diagnosis being treated with the requested agent

OR

  1. The prescriber states that the patient is receiving the requested agent AND is at risk if therapy is changed

AND

  1. If the requested agent is for an Affordable Care Act Copay Waiver product, that criteria has been met

Length of Approval:  12 months

        Table 1: List of drugs/drug classes/medical conditions that are excluded from coverage on the pharmacy benefit

Products Excluded from the Pharmacy Benefit

How to Identify

HIM

ASO and Merit Rated Groups

NetResults A Series

SourceRx

AHFS (devices and pharmaceutical aids, except for continuous glucose monitor sensors, readers, transmitters and receivers)

AHFS code 940000000 (DEVICES) and/ or 960000000 (PHARMACEUTICAL AIDS)

X

X

X

X

Anorexic/Weight Loss (except for Imcivree)/Weight Management

Third Party Restriction Code 8

-OR-

FDA-indication or diagnosis of weight loss

-OR-

Any of these GPIs:

6120**********

6125**********

X

Contraceptives [Implants, IUD, jellies, creams, foams]

X

X

Cosmetic Alteration (includes botulinum toxin products)

Third Party Restriction Code C

X

X

X

X

Diabetic Supplies (Lancet devices, glucose meters control solution, ketone blood test strips, urine tests, alcohol swabs, glucose [OTC])

X

X

X

NetResults covers lancet devices and control solutions

X

Diagnostic Agents (e.g. pregnancy tests, radiographic contrast, except for diabetic test strips)

Third Party Restriction Code 5

X

X

X

X

General Anesthesia

Third Party Restriction Code 6

X

X

X

X

Institutional Packs

Modifier codes in the product detail (AAAD31, BBAD9A, TTAAJQ,  TTAA5V, AAAB9A, AAADQQ, AAAD6T)

X

X

X

X

Medical Devices (e.g. bandages, non-insulin syringes and needles, except for continuous glucose monitor sensors, readers, transmitters and receivers)

GPI 97*

X

X

X

X

Multi-source Code (MSC) O

X
Benefit for plans with mandatory generic and member pays the difference, otherwise formulary exception

X
Benefit for plans with mandatory generic and member pays the difference, otherwise formulary exception

X
Benefit for plans with mandatory generic and member pays the difference, otherwise formulary exception

X
Benefit for plans with mandatory generic and member pays the difference, otherwise formulary exception

Non-FDA Approved Products and Compound Kits

Included on FID 213, Tiers 1, 2, 3, 4 and 7

X

X

X

X

Non-FDA Approved Products (e.g. bulk powders) and Compound Kits

Included on FID 216

X

X

(may vary for ASO groups)

X

X

Ostomy Supplies

Third Party Restriction Code 3

X

X

X

X

OTCs (except for diabetic test strips)

Rx-OTC Indicator of ‘O’ or ‘P’

X

X

X

X

Prescription Drugs with OTC Equivalents

Defined by an Rx NDC (Rx-OTC indicator R or S) with an OTC NDC (RX-OTC indicator O or P) within the same GPI 14 in the product file in RxClaim

X

X

Repackagers

Repackager field = Y

X

X

X

X

Respiratory Supplies (e.g. Spacers, nebulizers, and Peak Flow meters)

X

X

X

X

Surgical Supplies

Third Party Restriction Code 3

X

X

X

X

Universal Product Code (UPC) and Health Related Item Code (HRI) (except for diabetic test strips)

Product Type 1 (UPC) and Product Type 2 (HRI)

X

X

Vaccines

AHFS code 80120000 (VACCINES)

X (may vary for ASO groups)

This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
 
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
 
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.

ALBP_CS_ Coverage_Exception_ProgSum_10-01-2024  © Copyright Prime Therapeutics LLC. 08/2024 All Rights Reserved                                        Effective: 10/01/2024