Blue Cross and Blue Shield of Illinois

 

April 4, 2014

Pharmacy Program Quarterly Update – First Quarter 2014

This is the first in a series of quarterly updates to remind readers of recent Pharmacy Program initiatives.* The following changes were implemented for the first quarter of 2014:

  1. Self-Administered Specialty Drugs System Edit Expanded
    To receive coverage for specialty medications approved for self-administration by the U.S. Food and Drug Administration (FDA), members are required to use their prescription drug benefit and acquire the medication through a contracted pharmacy provider and not through a medical provider. These drugs can include oral, topical and self-injectable products.

    To ensure that the correct benefit is applied, a system edit was implemented in January 2013 that redirects claims for various self-administered specialty drugs submitted for processing under the medical benefit to the prescription drug benefit. This system edit was recently expanded further on July 1, 2013 and on Jan. 1, 2014. The January expansion included infertility, oral oncology and various other self-administered specialty medications.

    Note: This system edit was implemented for all members with prescription drug benefits through  Blue Cross and Blue Shield of Illinois (BCBSIL), as well as for members with prescription drug benefits through another pharmacy benefit manager (PBM).

  1. Utilization Management (UM) Program Updates
    New Specialty Prior Authorization Programs – Cushing’s Disease, Familial Hypercholesterolemia, Short Bowel Syndrome and Urea Cycle Disorders

        •    For Standard Insured groups, effective Jan. 1, 2014, upon renewal, these new drug categories are          automatically added to the standard UM program.
        •    Custom Insured and ASO groups will need to provide approval before these new drug categories can          be added to their benefits, even if the group currently has the standard UM program.
     
  2. Formulary and Drug Dispensing Limits Changes
    Based on the availability of new prescription medications and routine review of changes in the pharmaceutical market, revisions are regularly made to both the formulary and dispensing limits. View the most up-to-date formulary and drug dispensing limits on bcbsil.com.
     
  3. Transition to Integrated BlueScriptSM
    Illinois members who had a BlueScript plan were migrated to Integrated BlueScript plans effective on or after Jan. 1, 2014, when the accumulators reset to zero. Impacted members received new ID cards prior to the change.

    Note: Some members/groups were not included in the transition.
     
  4. Coverage for Select Preventive Vaccinations Added to Pharmacy Benefit
    Effective Jan. 1, 2014, upon renewal, coverage of select vaccinations is added to the prescription drug benefit. This change increases members’ access to obtain these vaccines at participating Prime Therapeutics vaccine network pharmacies with a $0 member share (no copayment or deductible). (Coverage is still available under the member’s medical benefit if obtained at their doctor’s office.)

Vaccinations include:
    •    Influenza (flu)
    •    Pneumococcal (pneumonia)
    •    Zoster (shingles)
    •    Rabies
    •    Hepatitis B
    •    T-Dap (diphtheria, tetanus and pertussis)
    •    Tetanus

Note: This benefit does not apply to HMO or grandfathered groups.

Contact your BCBSIL representative for more information on any of these pharmacy initiatives.

*These initiatives apply to prescription drug plans administered through Blue Cross and Blue Shield of Illinois (BCBSIL).

Prime Therapeutics LLC is a pharmacy benefit management company. BCBSIL contracts with Prime Therapeutics to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. In addition, contracting pharmacies are contracted through Prime Therapeutics. The relationship between BCBSIL and contracting pharmacies is that of independent contractors. BCBSIL, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.

 
 


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