For Members
Biological treatments can offer significant benefits, including targeted action and improved outcomes for conditions like rheumatoid arthritis, cancer, inflammatory bowel disease and autoimmune diseases.
Here’s what you need to know:
- Coverage and Eligibility: Check your health insurance policy to understand the coverage for biological treatments. Ensure you meet any specific eligibility criteria, such as medical necessity and prior authorization requirements.
- Prior Authorization: All biologics require prior authorization. Work closely with your healthcare provider to ensure all necessary documentation is submitted for approval.
- Provider Network: Treatments must typically be administered by a healthcare provider within your providers network. Verify that your provider is authorized to deliver the biologic treatment you need.
- Cost Considerations: Be aware of potential out-of-pocket costs, including deductibles, copayments, or coinsurance.
Biologics are typically administered via injection or infusion rather than orally, as they are proteins that would be broken down in the digestive system. They often target specific components of the immune system, making them effective for conditions that involve immune system dysfunction.
For Healthcare Providers
As a healthcare provider, your role is crucial in ensuring patients receive the appropriate biologic treatments. Here’s how you can support your patients:
Top of Form
The approval requirements for biologic treatments from an insurance company can vary depending on the type of biologic treatment, and the patient’s individual health plan. However, there are some common steps and considerations that typically apply:
- Medical Necessity: Nextcare usually requires documentation that demonstrates the medical necessity of the biologic treatment. This often includes a diagnosis from a healthcare provider, a detailed treatment plan, and evidence that other treatments have been tried and were ineffective.
- Prior Authorization: Nextcare requires prior authorization covering a biologic treatment. This involves submitting detailed information about the patient’s condition and the proposed treatment to the insurer for review.
- Clinical Guidelines: The treatment must align with established clinical guidelines or standards of care for the specific condition being treated.
It’s important for patients and healthcare providers to work closely with the insurance company to ensure all necessary documentation is submitted and any specific requirements are met. Additionally, patients should review their health insurance policy to understand coverage limits, exclusions, and any potential out-of-pocket costs.
General approval requirements:
- Disease severity score
- Pre-biologic labs.
- Baseline markers
- Treatment and monitoring plan
Example Checklist for Biologic prescription approval for Inflammatory Bowel Disease (IBD)
- Onset, duration of symptoms, previous management and treatment history.
- SESCD (Crohn’s disease), Mayo (UC), classification (mild, moderate, severe).
- HCV AB, TB QuantiFERON, Serotonin.
- CBC, CRP, fecal calprotectin, liver enzymes, bilirubin and Hyaluronic acid
- Extent of the disease (stricture or fistula).
- Dosage (initial + maintenance), treatment duration
