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Blue Shield reports fixes after reviewing infertility denials; will expand specialty pharmacy access
Summary
Blue Shield told the SFHSS board it reviewed 215 infertility cases from 2018–2019, overturned 54 prior denials, has four pending cases expected to be approved, and plans additional pharmacy contracts by November to ease access to fertility medications.
Blue Shield presented an update on infertility claims and access after board and member concerns about denials.
Blue Shield said its clinical review found 215 infertility cases for SFHSS members for 2018–2019. Of those, 54 prior denials were reprocessed and overturned, seven were determined not to be covered services, and four cases remained pending but were expected to be approved following case‑note review.
The vendor described operational fixes: designation of internal clinical subject matter experts for infertility claims, updated medical policy and authorization timelines tailored to infertility workflows, education for accountable care organization providers on referrals and benefit interpretation, and an improved referral workflow to connect members with specialty pharmacies that dispense fertility medications. Blue Shield noted it already contracts with CuraScribe/Freedom Pharmacy for fertility drugs and said it is seeking additional pharmacy contracts to increase member options, with new agreements anticipated by November.
Commissioners requested follow‑up on outcomes for members whose earlier claims were delayed or denied and stressed the importance of monitoring pricing and pharmacy market consolidation (noting CuraScribe’s ownership changes) as potential drivers of higher specialty drug costs. Blue Shield agreed to return with updates on pharmacy contracting and a report back to the board on member remediation and access results.
The board did not take a separate vote on the presentation; it requested subsequent follow‑up information.
