Blue Cross and Blue Shield of Illinois

 

 

March 29, 2013

July 1, 2013 System Edit to Redirect Claims Processing for Additional Self-Administered Specialty Drugs

To receive coverage for specialty medications that are self-administered, your employees are required to use their prescription drug benefit and acquire the medication through a pharmacy provider and not through a medical provider.

Specialty medications are generally prescribed for people with complex or ongoing medical conditions, such as multiple sclerosis, hemophilia, hepatitis C and rheumatoid arthritis. These medications can include oral, topical and self-injectable products.

Some specialty medications must be given by a health care professional, while other specialty medications are approved by the U.S. Food and Drug Administration (FDA) for self-administration. Medications that require administration by a health care professional are usually covered under an employee’s medical benefit and are obtained and supplied by the employee’s physician. Coverage for self-administered specialty medications is provided through an employee’s prescription drug benefit. In this case, the doctor must write or call in the prescription for the specialty drug that the employee then receives from a pharmacy provider.

As previously communicated, to ensure that the correct benefit is applied, Blue Cross and Blue Shield of Illinois (BCBSIL) implemented a system edit, effective Jan. 1, 2013, to redirect services submitted for certain self-administered specialty medications on all professional claims. An additional system edit is scheduled for July 1, 2013, to redirect professional claims for hemophilia (i.e., factor drugs), hepatitis C and multiple sclerosis drugs.

As a reminder, Prime Specialty Pharmacy is the preferred specialty pharmacy for most BCBSIL members. Medication can be shipped directly to your employee’s home or designated alternate location. For prescription drug benefits that are not supported by Prime Therapeutics, the purchasing of the self-administered drug should go through your current pharmacy benefit manager.

To help members and providers verify the correct path for medication fulfillment and ensure that the correct benefit is applied, we offer a list of drugs FDA-approved for self-administration. On the list, medications covered under the medical benefit have an (M) placed after their names. The rest of the medications are approved for self-administration and are covered under the prescription drug benefit in most circumstances.

If you have further questions about this change, please contact your BCBSIL representative.

Prime Therapeutics Specialty Pharmacy LLC (Prime Specialty Pharmacy) is a wholly owned subsidiary of Prime Therapeutics LLC, a pharmacy benefit management company. Prime Therapeutics LLC is a partially-owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an independent licensee of the Blue Cross and Blue Shield Association. Blue Cross and Blue Shield of Illinois (BCBSIL) is a Division of HCSC, which contracts with Prime Therapeutics LLC to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services.

 


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A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association.