- Radiology utilization for Arkansas Blue Cross FEP
Carelon Medical Benefits Management operates the Radiology Utilization Management Program.
- Medical pharmacy
Pharmaceutical therapies administered by a provider and billed through the medical benefit.
- Retail pharmacy
Medications covered under the pharmacy benefit are typically those that can be self-administered by the patient.
- Step therapy protocol exception
In 2021, the Arkansas legislature passed Act 97 requiring an exception request process for drugs identified by the health plan as subject to step therapy.
- Prior authorization
The primary coverage criteria of certain services must be established through a prior authorization process before they can be performed.
An outpatient diagnostic imaging program is active (since September 1, 2006) for individual and group members of Arkansas Blue Cross and Blue Shield health plans, except for members of Medicare Supplement, Medicare Advantage, Access Only, AR Health (where Medicare is primary), BlueCard (check with home plan if not Arkansas) and the Federal Employee Program (FEP).
Physicians are required to secure prior authorization for the following outpatient procedures: CT Scan, MRI/MRA, Nuclear Cardiology and PET Scan.
Arkansas Blue Cross utilizes Carelon Medical Benefits Management - an independent company - to provide prior authorization of health plan coverage services.
Certain Octave Blue Cross plans utilize Carelon Medical Benefits Management, an independent company, to provide prior authorization of health plan coverage for medical oncology medications for members of its individual and group plans. Please contact customer service at the number on the back of the ID card for verification.
Providers are required to secure a prior authorization for medical oncology medications. Providers may submit a request to Carelon Medical Benefits Management.
How to understand which medications require a prior authorization through Carelon medical oncology program:
- Medical oncology medication list | (machine readable)
- Review applicable coverage policy. Oncology benefits management program is listed at the top of the policy.
For BlueMedicare members, please see Medicare Advantage.
For Federal Employee Program (FEP) members, please see Specialty Pharmacy.