Coming Soon! New Drug Requirements for Medical Pharmacy Benefits

Coming Soon! New Drug Requirements for Medical Pharmacy Benefits

4/26/2016

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan have been managing specialty drugs under the pharmacy benefit for several years through prior authorizations, preferred drug strategies and drug exclusions. Within the past year, we have also implemented management of specialty drugs under member medical benefits. Effective June 1, 2016, BlueCross and BlueChoice® will implement two specialty drug requirements:
  • 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. This change will affect some members’ out-of-pocket costs. Providers prescribing specialty drugs billed under the member’s pharmacy benefit will continue to request prior authorizations as usual through CVS/caremark, a division of CVS Health, an independent company that provides pharmacy services on behalf of BlueCross and BlueChoice.
    Note: These specialists can continue to bill self-administered drugs under the member’s medical benefit:
    • Hematologists
    • Oncologists
    • Nephrologists
    • Rheumatologists 

BlueCross and BlueChoice plans not included in this benefit are the Federal Employee Program (FEP), State Health Plan, and out-of-state members (BlueCard®).

More information about prior authorizations for medical specialty drugs through Novologix, to include training materials and self-administered drug lists, will be available on our websites, www.SouthCarolinaBlues.com and www.BlueChoiceSC.com, in the Provider Education sections, as the implementation date approaches.

Please contact Provider Education for information about this bulletin at provider.education@bcbssc.com or by calling 803-264-4730.

BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.