June 22, 2022

As more specialty drugs are being covered under both the medical and pharmacy benefits, the need to determine the most appropriate coverage option is increasing. To help simplify this complex specialty drug environment, BlueCross BlueShield of South Carolina and Optum Rx^®, our pharmacy benefits manager, have developed Specialty Fusion — a user-friendly prior authorization (PA) platform for specialty drugs covered under the medical benefit, pharmacy benefit or both.

Phase 1 of the Fusion implementation launches on July 1, 2022. On that date, providers can begin to use the existing MBMNow portal to request PA for specialty drugs under the pharmacy or medical benefit, improving the overall provider experience by creating a single destination for specialty drug PA requests. Previously, MBMNow was limited to authorizations under the medical benefit only.

Fusion is only available to carve-in groups that currently utilize MBMNow as part of Specialty Medical Benefit Management (SMBM). Additional Fusion functionality that will be available on July 1 includes:

• Authorization capabilities around antiemetic drugs used with chemotherapy. The following antiemetic drugs must now get prior authorization when prescribed as part of a cancer treatment regimen:
  • Akynzeo (palonosetron/Fosnetupitant) injection
  • Aloxi (palonosetron) injection
  • Cinvanti (aprepitant) injectable emulsion
  • Emend (Fosaprepitant) injectable emulsion
  • Kytril (granisetron) injection
  • Sustol (granisetron extended release) injection
  • Zofran (ondansetron) Injection

Note: For current members with valid antiemetic drug claims in their history 90 days prior to July 1, 2022, such members will be allowed to continue their current antiemetic therapy as long as there is claim history to confirm active therapy. Members with NO claim history (i.e., new to therapy) who are prescribed an antiemetic medication 90 days prior to July 1, however, will be subject to authorization through Fusion.

• Implementing pathways. When a provider requests PA for cancer treatment medications, MBMNow will recommend high efficacy/low toxicity treatment pathways based on NCCN guidelines. Pathways are available for 19 different cancers and were developed by a dedicated team of oncology experts. Pathways are updated periodically to reflect the latest evidence. Providers will not be required to adhere to the pathways.
• Implementing dosage rounding for cancer drugs under the medical benefit, which rounds approved dosage by up to 10 percent when doing so prevents the provider from using a fraction of a vial and discarding the rest.

Future enhancements to Fusion will allow MBMNow to guide providers to the most appropriate coverage option — medical or pharmacy — for each member based on his or her specific benefit.

If you have any questions about this bulletin, you can reach out to the provider education team at 803-264-4730 or Provider.Education@bcbssc.com. 

*Optum Rx is an independent company that handles pharmacy benefit management on behalf of BlueCross BlueShield of South Carolina.