Self-administered specialty drug claim processing reminder
As a reminder, beginning January 1, 2014, Blue Cross and Blue Shield of New Mexico (BCBSNM) expanded its claims processing system edit to redirect professional electronic (837P) and paper (CMS-1500) claims for fertility, oral oncology, and various other select self-administered specialty drugs.* Specialty drugs approved by the U.S. Food and Drug Administration (FDA) for self-administration must be billed under the member’s pharmacy benefit for members to receive coverage consideration.
Members impacted by the recent claim system edit expansion were advised through letters sent in late October. These member letters included a sample list of self-administered specialty medications, along with instructions on how to obtain these specialty medications and whom to call for assistance, if needed.
To help providers determine the correct path for medication fulfillment and ensure that the correct benefit is applied, a Specialty Pharmacy Program Drug List is available in the Pharmacy Programs/Commercial section of our website.
- This list identifies medications that require administration by a health care professional, and are often covered under a member's medical benefit.
- This list also identifies specialty drugs that are approved by the U.S. FDA for self-administration, and are usually covered under the member's pharmacy benefit. For these self-administered drugs, the member's physician must write or call in the prescription to a pharmacy provider that is contracted to provide specialty services.
A specialty pharmacy program drug list is also available as a reference for your patients on our website, at bcbsnm.com/member. In accordance with their benefits, members may be required to use a preferred specialty pharmacy. Providers and members may call the number on the member’s ID card to verify coverage or obtain clarification on the member’s benefits.
*The various other select specialty drugs of this system edit expansion include: Actimmune, Apokyn, Firazyr, Fuzeon, Leuprolide Acetate, Octreotide Acetate, and Stelara.
Third-party brand names are the property of their respective owners.
Pharmacy benefits and limits are subject to the terms set forth in the member’s certificate of coverage which may vary from the limits set for the above. The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions.
Blue Review • January 2014 • bcbsnm.com