03/06/2024

BCBSM Increased Denials in Auths – Same Drug, Different Manufacturer Update

During MSHO's "Now that the Dust Has Settled" webinar last month, we discussed the increased denials in authorizations on the same classification of drug but from different manufacturers who have assigned HCPCS codes specific to that manufacturer. This is because the FDA has established unique HCPCS codes for generic drugs approved under the FDA’s 505 (b) new drug application (NDA) and biologics license application (BLA) pathways.  As generics and biosimilars are approved via this pathway and are not rated as therapeutically equivalent to their reference drug, they are considered single source drugs. 

When a provider requests authorization for one of the original products and/or its counterpart, another product may be utilized to take advantage of decreased costs. This causes a denial in the claims system, as the drug product may change over the course of the regimen, but the auth is only for the initial product ordered. Central supply departments or those individuals responsible for purchasing your drugs are working to utilize the lowest cost product, which may not align with the auth on file.  

MSHO has heard your frustration and we have been working with our BCBSM team to help.  Below is the temporary solution BCBSM has offered our members.  Please note BCBSM is working toward a permanent resolution in 2025.  

• Commercial is manually updating all authorizations to include all pertinent HCPCS codes. 
• Provider offices are to status any denied claims in 3 weeks from today (3-21-2024).  
• We will be reviewing monthly and updating the authorizations.

Please let MSHO know if you are experiencing any delays in payment after you status your claims.  If anyone is experiencing similar issues with other payers please send an email to billing@msho.org.  As we receive updates from other payers we will address and keep our membership apprised.