CurrentBlue Cross Blue Shield - IowaPolicy N/A

High Dollar Pharmacy Claim Review Criteria

Defines clinical review criteria Wellmark uses to evaluate high-cost pharmacy and medical drug claims and applies to providers submitting requests for drugs exceeding specified dollar thresholds; affects members and prescribing providers under Wellmark benefit plans (except where noted).

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyHigh Dollar Pharmacy Claim Review Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 25, 2024

Next Review DateN/A

Key ActionSubmit prior authorization with documentation showing indication, prior therapy attempts when applicable, and dosing consistent with labeling or accepted compendia.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

$34,999.99pharmacy claim dollar threshold

$100,000medical claim dollar threshold

12 monthsmax approval duration

Jan 2016policy creation

Oct 2024most recent review

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage criteria and scope

inv-01: Initial Therapy

The requested drug may be considered medically necessary when ALL of the following criteria is met:

Initial approval

Indication: The requested drug must be used for an FDA‑Approved indication OR an indication supported in accepted compendia (e.g., AHFS, guidelines)
Prior therapy: The patient must have tried and failed established FDA‑approved and/or clinical guideline‑recommended therapy prior to the requested drug, if applicable, unless contraindicated
Dosing and quantity: Prescribed quantity, dosing frequency, and duration of use must fall within manufacturer's published dosing guidelines or within dosing guidelines found in accepted compendia (examples: package insert; AHFS; Micromedex; current accepted guidelines)
Documentation: Provider must submit necessary documentation to support the diagnosis and the clinically appropriate use of the drug

inv-02: Continuation Therapy

The request for continuation of therapy may be considered medically necessary when ALL initial authorization criteria are met AND clinical documentation is provided showing the patient has achieved and/or maintained a positive clinical response with the requested therapy.

Continuation approval: All initial authorization criteria plus documentation of achieved or maintained positive clinical response

Approval will be for the FDA‑Approved duration of treatment OR a duration of treatment supported in the compendia of current literature not to exceed 12 months

This policy applies only to drugs that are not currently managed through drug‑specific prior authorization programs. High‑dollar review is performed for pharmacy claims exceeding $34,999.99 per claim and medical claims exceeding $100,000 per claim; drugs already subject to drug‑specific prior authorization are excluded unless a change after that drug‑specific approval necessitates further review.

Requests that do not meet the initial approval criteria will be considered not medically necessary. Examples include use for a non‑FDA or non‑compendia supported indication, failure to document prior appropriate therapy when required, prescribed dosing or quantity outside manufacturer or accepted compendia guidelines, or insufficient supporting documentation. Providers should submit complete documentation showing indication, prior therapy attempts (or contraindications), and dosing consistent with labeling to avoid denial.

Coding and claim thresholds

Procedures/Billing codes (general guidance)mixed

Code(s) , if applicable

Placeholder indicating use of appropriate CPT, HCPCS, Revenue, and/or ICD diagnostic codes as applicable

inv-06: Pharmacy claim review threshold — $34,999.99

Pharmacy claim review threshold$34,999.99 per pharmacy claim

Applies toDrugs not already managed through drug‑specific prior authorization (unless subsequent changes require review)

Purpose of reviewEnsure safe, clinically appropriate, and cost‑effective use and verify proper quantities and costs

inv-07: Medical claim review threshold — $100,000

Medical claim review threshold$100,000 per medical claim

Applies toDrugs not already managed through drug‑specific prior authorization (unless subsequent changes require review)

Provider requirements and authorization process

Prior Authorization

High dollar claim prior authorization thresholds

Prior authorization review is required for high-dollar pharmacy and medical drug claims to ensure safe, clinically appropriate, and cost‑effective use. Requests are reviewed when pharmacy claims exceed $34,999.99 and medical claims exceed $100,000. This policy applies to drugs not already managed under drug‑specific prior authorization unless a subsequent change triggers additional review.

Pharmacy threshold: > $34,999.99 per claim
Medical threshold: > $100,000 per claim

Step Therapy

Step requirement

The patient must have tried and failed established FDA‑approved and/or guideline‑recommended therapy prior to the requested drug, when applicable, unless such therapies are contraindicated.

Background and intent

The purpose of high‑dollar drug review is to ensure the safe, clinically appropriate, and cost‑effective use of requested medications by confirming the indication, prior therapy attempts, and that dosing and quantities align with FDA‑approved labeling or accepted compendia. Reviews for pharmacy claims over $34,999.99 and medical claims over $100,000 help verify proper quantities and costs and provide safeguards against unnecessary utilization.

Key definitions

inv-13: High dollar drug — defined as a drug subject to review when a pharmacy claim exceeds $34,999.99 or a medical claim exceeds $100,000

DefinitionHigh dollar drug: a drug subject to review when a pharmacy claim exceeds $34,999.99 or a medical claim exceeds $100,000.

Review intentTo ensure appropriate prescribing, quantities, dosing per FDA labeling or accepted compendia, and cost‑effectiveness

ScopePolicy applies only to drugs not currently managed through drug‑specific prior authorization unless changes after approval require review

Initial therapy requirements

inv-14: Initial Therapy

Initial approval requires meeting all criteria below.

Initial therapy: Indication supported by FDA or accepted compendia; patient has tried and failed established FDA‑approved or guideline‑recommended therapy if applicable (unless contraindicated); prescribed quantity/dosing frequency and duration are within manufacturer's or compendia guidelines; provider submits necessary supporting documentation

Approval duration per FDA or compendia not to exceed 12 months

Continuation of therapy requirements

inv-15: Continuation of Therapy

Continuation requests require meeting initial criteria and evidence of clinical benefit.

Continuation: Initial criteria met AND documentation showing the patient has achieved and/or maintained a positive clinical response with the requested therapy

Approval will be for the FDA‑Approved duration of treatment OR a duration of treatment supported in the compendia of current literature not to exceed 12 months

Step therapy / prior treatment requirements

Step	Requirement
1	Patient must have tried and failed established FDA‑approved and/or guideline‑recommended therapy prior to the requested drug, if applicable, unless contraindicated.