Effective September 1, 2013, Blue Cross Blue Shield of Michigan (BCBSM) will implement a new Prescriber Prescription Block Policy. The policy focuses on protecting patient and public safety.
Under the new policy, prescriptions will no longer be payable if:
• A provider prescribes drugs that are not medically necessary, may cause significant patient harm, or are not appropriate for the documented medical condition.
• A provider is being investigated for fraud, waste, or abuse.
• A provider has been sanctioned at the time the prescription is dispensed. A provider may be sanctioned by the Office of the Inspector General, the Government Services Agency, the Centers for Medicare & Medicaid Services, or state licensing boards. BCBSM will notify sanctioned providers if they fall under the purview of the Prescriber Prescription Block Policy as well as affected members who have had a prescription written by a sanctioned provider within the past four months. Following notification, all prescription claims ordered by a sanctioned provider will be rejected. The block will be effective for five years or more.
BCBSM provided a list of steps it will take prior to acting under the new policy in order to prevent blocking a provider unnecessarily. The list includes, but is not limited to:
• Conduct an investigation to review the past 60-days of the prescriber’s activity,
• Obtain opinions from BCBSM medical consultants,
• Present findings and obtain approval for a provider sanction from BCBSM executive leaders and the Audit Investigative Committee.
Pharmacies will be notified at the point-of-sale that a prescriber is sanctioned by both a fax-blast communication and an electronic message. In such a situation, the member may choose to pay for the prescription out of pocket but he will not be reimbursed by BCBSM.