Enhancement to Medical Drug Benefit Program Managed by CareContinuum, Effective January 1, 2023

The 1199SEIU Benefit Funds have enhanced our Medical Drug Benefit Program managed by CareContinuum, an Express Scripts company, to help ensure that your patients continue to receive drug therapy that meets the standard of care and to streamline the claims process by reducing claim line edits.

Enhancements to the program include a 10 percent variance added to IVIG authorized units to accommodate patient weight changes during an authorized period of care. The 10 percent variance will help ensure that more billable units are paid to providers in the claim submission process during the IVIG authorization period. Please provide CareContinuum with updated clinical information to avoid adverse claim edits if there is a change in a member’s weight, IVIG dosage or frequency of administration.

An additional enhancement to the program is the introduction of the Benefit Funds’ biosimilar-first policy for non-oncology indications of the rituximab therapeutic class. Biosimilar products, which mimic the reference product in structure and function, have no clinically significant differences to the U.S. Food and Drug Administration-approved reference biologic products, as confirmed by rigorous testing and analysis. The program will refer the selection of drugs to preferred products within the therapeutic class. At least one preferred product will be required prior to the approval of a non-preferred product. Prior authorization will still be required for both preferred and non-preferred products. To learn more, visit the CareContinuum website or call (877) 273-2122.

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