Sept. 3, 2015

Specialty Pharmacy Preferred Channel Management, Effective Nov. 1, 2015

Starting Nov. 1, 2015, Blue Cross and Blue Shield of Oklahoma (BCBSOK) reimbursement rates are being adjusted for select medications identified as specialty pharmacy products with Preferred Channel Management. Reimbursement for these products will be reflected in the BCBSOK National Drug Code (NDC) fee schedule and based on the maximum allowable per package NDC unit of measure (i.e., UN or unit, ML or milliliter, GR or gram, F2 or International unit).

In order to help reduce the physician’s up-front acquisition cost to obtain these non-self-administered or office-based specialty medications, you can use our Preferred Channel Management resources:

• Prime Therapeutics Specialty Pharmacy LLC (Prime Specialty Pharmacy) for most specialty products
• Pharmacy Solutions (AbbVie) for Lupron Depot specialty products

The specialty pharmacy will bill BCBSOK for the medication. You may continue to bill for administration of the specialty drug, along with any office visit related codes.

For more information about obtaining specialty products from these vendors for office administration, please refer to the Specialty Pharmacy section of our Provider website at bcbsok.com/provider.

Reminder: For specialty medications that may require you to submit a prior authorization (PA) request before your patient receives coverage, you can find the following electronic submission resources on our website:

• CoverMyMeds^®, an online tool for electronic completion of PA requests for drugs considered eligible for coverage under the member’s pharmacy benefit.
• Aerial^TM iExchange^® (iExchange), our web-based automated tool that accepts benefit prior authorization requests for these select specialty drugs considered eligible for coverage under the member’s medical benefit: Avastin, Mybloc, Reclast, Botox and Remicade.

Prime Therapeutics Specialty Pharmacy LLC (Prime Specialty Pharmacy) is a wholly owned subsidiary of Prime Therapeutics LLC, a pharmacy benefit management company. Blue Cross and Blue Shield of Oklahoma (BCBSOK) contracts with Prime Therapeutics to provide pharmacy benefit management and related pharmacy services. BCBSOK, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.

CoverMyMeds is a registered trademark of CoverMyMeds LLC, an independent third party vendor that is solely responsible for its products and services. BCBSOK makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors. If you have any questions regarding the products or services they offer, you should contact the vendor(s) directly.

The listing of any particular drug or classification of drugs is not a guarantee of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, terms, conditions, limitations and exclusions set forth in the member’s policy or benefits document. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions.
Regardlessofbenefits, thefinaldecision about any medication is between the member and their health care provider.