Pharmacy Optimization Initiative Highlights – 4th Quarter 2014

Posted March 17, 2015 

Blue Cross and Blue Shield of Illinois (BCBSIL) continues to enhance the pharmacy program services and support we make available to you and your patients. This brief 4th quarter summary highlights recent BCBSIL pharmacy initiatives and provides helpful reminders with links to related resources. 


GuidedHealth® Program Updates

BCBSIL uses the GuidedHealth clinical rules platform to help monitor and promote appropriate use, safety and cost effectiveness of medications prescribed to our members. Informational letters are sent to providers regarding patients who may have potential drug therapy issues, as identified based on BCBSIL claims data. The member may also receive a letter. In the fourth quarter 2014, letters were sent to prescribers regarding potential non-adherence to medications.

Bulk Powder Compounds Updates

In recent articles, we reported that an increasing number of claims for compound drug products have been identified that are not covered benefits as they do not meet the limited exception criteria under the BCBSIL Medical Policy for benefits coverage of compound drug products formulated from bulk powders. For dates of service on or after Feb. 1, 2015, claims submitted to BCBSIL for compound drug products using bulk powders will be denied in accordance with the company’s Medical Policy. Details were published in the Nov. 14, 2014, News and Updates article titled, “Bulk Powder Compounds: Claim Processing Change, Effective Feb. 1, 2015”* .

Insulin Formulary Changes and New Prior Authorization Program Updates

Starting Jan. 1, 2015, BCBSIL changed its formulary to make Novo Nordisk®’ insulin products the preferred brands for members with prescription drug benefits administered through Prime Therapeutics. Additionally, a new Insulin Agents prior authorization (PA) program was implemented.**

Affected members have been notified of this change. They have been instructed to contact their physician to discuss their insulin drug choices and determine if a preferred brand is right for them. Refer to the Jan. 19, 2015, News and Updates article titled, ”Insulin Formulary Changes and New Prior Authorization Program in 2015”  for details regarding these changes.



CoverMyMeds is an online tool available to BCBSIL independently contracted providers for electronic completion and submission of benefit prior authorization (PA) requests for prescription drugs that are part of the BCBSIL pharmacy PA program. Visit the CoverMyMeds page in the Provider Tools section to get started and learn more. 

Billing with National Drug Codes (NDCs)

When you bill with NDCs, in addition to including the appropriate HCPCS or Current Procedural Terminology (CPT®) information, BCBSIL can identify – and reimburse your office, in most instances, for – the individual medication that was prescribed.

Select Medication List

NDC pricing has paved the way for other initiatives, such as our Select Medication List, which is being developed in stages to include specific drugs within particular classes or categories, based on safety and cost effectiveness. Currently, the list includes two medications from the viscosupplementation class that are used primarily for osteoarthritis knee pain relief. Choosing a drug from the Select Medication List and billing for it with the appropriate NDC will result in a higher reimbursement rate than the rate applied for other non-listed drugs in the same class. View the current BCBSIL Select Medication List  for details.

General Information

Visit the Pharmacy Program section for information on drug formularies, dispensing limits, prior authorization/step therapy, specialty pharmacy and more. Also continue to watch our News and Updates and monthly Blue Review newsletter for details.

GuidedHealth is a registered trademark 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. BCBSIL makes no endorsement, representations or warranties regarding GuidedHealth. If you have any questions about this product or services, you should contact Prime Therapeutics LLC directly.

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

*This article does not apply to claims submitted by HMO members.

**Changes may be applied for some members, if applicable, based on their employer’s 2015 group plan renewal, or new plan effective date. These changes do not apply to members with Medicaid or Medicare Part D coverage.

CoverMyMeds is a registered trademark of CoverMyMeds LLC, an independent third party vendor that is solely responsible its products and services.

Please note that the fact that a service has been preauthorized/pre-certified is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.

The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are instructed to exercise their own medical judgment. 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. Not all programs may be available to HMO members. 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. Regardless of benefits, the final decision about any medication is between the member and their health care provider.