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Self-administered Specialty Drug Update: Infertility and Oral Oncology Drugs

October 15, 2013

As a reminder, drugs approved for self-administration by the U.S. Food and Drug Administration (FDA) should not be submitted on professional/ancillary electronic (ANSI 837P) or paper (CMS-1500) claims.  Blue Cross Blue Shield of Illinois members are required to use their pharmacy benefit for U.S. FDA-approved self-administered specialty drugs (oral, topical and injectable) and obtain these medications through a pharmacy provider that is contracted to provide specialty pharmacy services.

Effective Jan. 1, 2014, the following message will be returned on the electronic payment summary or provider claim summary to providers billing for infertility, oral oncology and select additional medications: “Self-administered drugs submitted by a medical professional provider are not within the member’s medical benefits. These charges must be billed and submitted by a pharmacy provider.”

To help you determine the correct path for medication fulfillment and ensure that the correct benefit is applied, please refer to the Specialty Pharmacy Program Drug List  in the Pharmacy Program/Specialty Pharmacy section. 

Note:  In accordance with their benefits, members may be required to use a preferred specialty pharmacy. Please call the number on the member’s ID card to verify coverage or for further assistance or clarification on the member’s benefits. For members whose benefits require them to use Prime Therapeutics Specialty Pharmacy, you may fax the prescription to 877-828-3939 or call 877-627-MEDS (6337) for additional information. Medication(s) can be delivered to any requested location (e.g., member’s home or physician’s office). 

Pharmacy benefits and limits are subject to the terms set forth in the member’s certificate of coverage which may vary from the limits set forth above. The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. 

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