Blue Cross and Blue Shield of Illinois

 

 

May 17, 2013

Update: 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, members 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 a member’s medical benefit and are obtained and supplied by the member’s physician. Coverage for self-administered specialty medications is provided through a member’s prescription drug benefit. In this case, the doctor must write or call in the prescription for the specialty drug that the member then receives from a pharmacy provider contracted to provide specialty services.

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.

Impacted members will be advised through letters that were targeted to be mailed on May 15.

In accordance with their benefits, some members may be required to obtain these medications through a specialty pharmacy provider that is contracted to provide services through the Specialty Pharmacy Program in order to receive in-network benefits.

For Members with Prime Therapeutics as Their Pharmacy Benefits Manager
These members may call the Pharmacy Program number on the back of their member ID card or contact Prime Therapeutics Specialty Pharmacy at 877-627-MEDS (6337) to obtain their specialty medications.

In addition, for members who use factor medications, there are two preferred specialty pharmacy providers through which medications may be obtained. Members may select a specialty pharmacy provider by calling the Pharmacy Program number on the back of their member ID card, or contacting the vendors directly:

  • Accredo Health Group, Inc.(Accredo®)*: 866-712-5007
  • Prime Therapeutics Specialty Pharmacy: 877-627-MEDS (6337)

For Members Who Do Not Use Prime Therapeutics as Their Pharmacy Benefits Manager
Members who do not have Prime Therapeutics assigned as their pharmacy benefits manager may be required to use a preferred specialty pharmacy that is different from those listed above. Members should call either the Pharmacy Program or customer service number on the back of their member ID card to verify coverage or for further assistance.

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.

*Pending agreement

Prime Therapeutics Specialty Pharmacy LLC (Prime Specialty Pharmacy) is a wholly owned subsidiary of Prime Therapeutics LLC (Prime), a pharmacy benefit management company. Blue Cross and Blue Shield of Illinois is a Division of Health Care Service Corporation (HCSC), a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans. HCSC contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. HCSC, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime.


 
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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.