Blue Cross and Blue Shield of Illinois

 

September 20, 2013

Rx Update: System Edit to Redirect Claims Processing for Self-Administered Specialty Drugs to Be Expanded Jan. 1, 2014

Specialty medications are generally prescribed to treat chronic or complex medical conditions, such as multiple sclerosis, hemophilia, hepatitis C and rheumatoid arthritis. These medications are typically received by injection or infusion, but may include oral, topical and self-injectable products.

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

As previously communicated, to ensure claims are processed appropriately under the prescription drug benefit, Blue Cross and Blue Shield of Illinois (BCBSIL) implemented a system edit earlier this year to redirect services submitted for certain self-administered specialty medications on all professional claims. This system edit was expanded on July 1, 2013, to redirect professional claims for hemophilia (i.e., factor drugs), hepatitis C and multiple sclerosis drugs. Beginning Jan. 1, 2014, the system edit will be further expanded to redirect professional claims for fertility, oral oncology and various other select self-administered specialty drugs, such as Actimmune, Apokyn, Firazyr, Fuzeon, Leuprolide Acetate, Octreotide Acetate and Stelera.*

Impacted members will be advised through letters that are planned to be mailed in late October. The member’s doctor may also be alerted by letter, which would be mailed prior to the member notification.

In accordance with their benefit plan, some members may be required to obtain these medications through a specialty pharmacy provider that is contracted to provide services through their plan’s Specialty Pharmacy Program. Specialty Pharmacy Programs support members who require specialty drugs and help them manage their condition.

  • Members with Prime Therapeutics as their Pharmacy Benefit Manager may call the Pharmacy Program number on the back of their BCBSIL ID card or contact Prime Therapeutics Specialty Pharmacy at 877-627-MEDS (6337) to obtain their specialty medications.
  • Members who do not have Prime Therapeutics as their Pharmacy Benefit Manager may be required to use a different preferred specialty pharmacy provider. These members should call either the Pharmacy Program or customer service number on the back of their ID card to verify coverage or for further assistance.

A list of specialty drugs FDA-approved for self-administration is available on the bcbsil.com member and provider pages. On the list, medications that may be eligible for coverage under the medical benefit have an (M) placed after their names. Other medications on the list are FDA-approved for self-administration and are usually covered under the prescription drug benefit.

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

*Third-party brand names are the property of their respective owners.

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 (BCBSIL) 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.

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.