BlueCross® BlueShield® of South Carolina and BlueChoice HealthPlan require prior authorization for some specialty drugs billed under the medical benefit. Also, the medical benefit does not cover certain self-administered specialty drugs.
Drug costs continue to rise, and specialty drugs are contributing significantly to that trend. BlueChoice® has managed specialty drugs under the pharmacy benefit for several years, through prior authorization (PA), preferred drug strategies and, more recently, drug exclusions. We have also begun to manage specialty drugs under the medical benefit. Here are the current programs under the Specialty Medical Benefit Management (SMBM) strategy:
- Prior Authorization: Some medical (injectable/infusible) specialty drugs will require prior authorization through the CVS/caremark online prior authorization tool, Novologix, an industry-leading software system that assists in managing drugs reimbursed under the medical benefit. This tool is a web-based application available with single sign-on access through My Insurance ManagerSM.
- Self-administered Drugs: Certain self-administered drugs that were covered under the member’s medical benefit will only be covered under their pharmacy benefit. The pharmacy benefit will continue to cover these drugs. Hematologists, oncologists, nephrologists and rheumatologists may continue to bill these drugs under the medical benefit.
Which drugs are included on the medical prior authorization and self-administered drug lists?
Please see the two lists:
While these lists may change at any time, we expect to make changes quarterly.
Note: Prior authorizations for medical specialty drugs have always been a requirement for BlueChoice members. The attached is a comprehensive list that includes additional medical specialty drugs that require prior authorizations.
What other resources are available to assist me in learning more about prior authorizations for specialty medical drugs?
Here are reference materials about prior authorizations for specialty medical drugs:
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.