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Pre-certification Guidelines
If you are a doctor prescribing a specialty prescription drug for an Argus member, please adhere to the following guidelines to ensure that your patient receives the full prescription benefit:
- First, determine if the drug meets the Argus Health Specialty Prescription Drug definition and is on the approved specialty prescription drug list.
- Next, complete the pre-certification Coverage Request Form and submit to casemanagement@oneteamhealth.com. Please note that the prescribing doctor must submit the Coverage Request Form for pre-certification before the Specialty Drug is prescribed to the patient. In addition to completing the general provider and patient detail, the prescribing physician must also provide:
- evidence of Step Therapy, which requires the patient to commence treatment with the most cost-effective and safest Tier 1 drug therapy available before progressing to more costly or risky Tier 2 drug therapy, or
- clinical documentation from the managing physician as to why the patient should be exempted from Step Therapy. Step Therapy may include select over-the-counter products
- Physician and facility charges related to the administration of Specialty Prescription Drugs will only be payable at 100% if they are Tier 1 drugs, pre-certified by Argus and obtained within the Argus Specialty Prescription Drug Network; otherwise, benefits are payable at 50% or less, depending on the policy 1
- Upon review of the Coverage Request Form, Argus will reply in writing within five (5) working days. If approved, Argus will provide clear direction regarding next steps and the appropriate support services required for local and overseas drug treatments
- Please note that Specialty Prescription Drug pre-certification may be subject to approval every three (3) months for ongoing treatment
1 Signal, Signal Value & Classic cover 10% of inpatient facility charges only if not pre-certified and/or not in the Argus Specialty Prescription Drug Network
Have Additional Questions?
What are Specialty Prescription Drugs?
Specialty Prescription Drugs are defined in Argus Health policies as any injection, infusion, oral or inhaled drug on the approved specialty prescription drug list.
Specialty Prescription Drugs must be ordered by a physician and may require complex care, special storage and/or handling, patient education and/or continuous monitoring. These include but are not limited to:
- Biologics
- Biosimilars
- High-cost prescription drugs, having a value of $2,000 or more per thirty (30) day supply
- Drug therapies for the treatment of medical conditions such as:
- Cancer
- Rheumatoid and psoriatic arthritis
- Crohn’s disease
- Haemophilia
- Multiple sclerosis
- Hepatitis C
- Ankylosing spondylosis
How does Argus determine the list of approved Specialty Prescription Drugs?
Argus Health utilises the CVS Advanced Control Specialty Formulary to determine the list of approved Specialty Prescription Drugs, which can be found here.
How does Argus pay for drugs that are not on the approved Specialty Prescription Drugs list?
Drugs that are not included on the approved specialty prescription drug list will be covered under the usual prescription drug benefit (80% brand name, 100% generic).
What is the difference between the Specialty Prescription Drug Tiers?
Specialty Prescription Drugs on the approved specialty prescription drug list are assigned to one of two drug copayment tiers based on drug usage, cost and clinical effectiveness. Tier 1 drugs are preferred Specialty Prescription Drugs listed under one of the diagnostic groups (that the patient is being treated for) in the formulary and are covered at 100%, whereas Tier 2 drugs are listed under the section “Preferred Options for Excluded Specialty Medications” and are covered at 50%.
For additional information on the Specialty Prescription Drug Tiers and coverage stipulations for Step Therapy, Biosimilar Transition Programme, injectable drugs, and availability by jurisdiction, please email casemanagement@oneteamhealth.com
How does Argus assist with keeping the cost to the patient/member as low as possible?
We anticipate increased use of Specialty Prescription Drugs to treat and improve the quality of life for individuals managing certain diseases. Where possible, we will work with you, your patient and local pharmacies to source high-cost and Specialty Prescription Drugs from vendors offering the greatest value, thus minimising members’ out-of-pocket costs.
If members are receiving their drug treatments overseas, we can work with them and their managing physicians after their initial visits to explore the option of having the drug administered and monitored locally. We facilitate telemedicine visits to ensure clinical oversight by the overseas physician, thus saving the patient the time and money associated with travel.
What support services does Argus offer to patients/members undergoing Specialty Prescription Drug treatments?
Our dedicated Provider Relations Manager and Case Managers are clinical resources that give members personal attention and additional support to assist with the following:
- Coordinating care between the patient, their managing healthcare providers and their pharmacist
- Engaging, educating and communicating with patients and their support persons to help mitigate issues that could result in premature discontinuation of treatment
- Encouraging proactive use of health plan benefits and explaining policy provisions
To contact a Provider Relations Manager and/or Case Manager, please email insurance@argus.bm.
How does Argus support members who receive Specialty Prescription Drug treatments overseas?
Our overseas assistance office, One Team Health (‘OTH’), will provide logistical support to your patient if they are receiving treatment overseas. If your patient is receiving treatment in the U.S., they should fill their prescription at a CVS Pharmacy location. CVS will provide Specialty Prescription Drug Guideline Management through their approval process, and may engage OTH for review and approval at point of sale.
How can I ensure that my patient is able to maintain their drug treatment if they are returning from overseas care?
Our Overseas Medical Team at OTH and local Case Management Team work together to ensure that your patient receives seamless care between overseas and local providers and has access to their necessary prescriptions.
To contact our Overseas Medical Team, email casemanagement@oneteamhealth.com or, for a Case Manager, email insurance@argus.bm.