Prior Authorization Requirements for Specialty Drug Medical and Pharmacy Benefits

Prior Authorization Requirements for Specialty Drug Medical and Pharmacy Benefits

6/20/2017

Effective July 1, 2017, BlueCross BlueShield of South Carolina and BlueChoice® HealthPlan will deny all specialty medical drugs that are submitted without a required prior authorization and all specialty drugs that should be covered under the pharmacy benefit. Specialty drugs have been managed under the pharmacy benefit for several years through prior authorizations, preferred drug strategies and drug exclusions.

 
In 2016, we implemented management of medical specialty drugs under member medical benefits by requiring prior authorization for some drugs through the CVS/Caremark online prior authorization tool, NovoLogix, an industry-leading software system that assists in managing drugs reimbursed under the medical benefit. We also advised that certain self-administered drugs that were covered under the member’s medical benefit would only be covered under their pharmacy benefit. This requirement excludes State Health Plan (SHP) and Federal Employee Program (FEP) members.
 
What you should know:
  • Prior Authorization: Some medical (injectable/infusible) specialty drugs will require prior authorization through, NovoLogix. This tool is a web-based application available with single sign-on access through My Insurance ManagerSM

If no prior authorization is obtained, you will receive the following edit on your remittance:

 

 Remittance Type  Code   Description 
 Electronic  197  Precertification/Authorization/Notification absent
 Hardcopy  9331  This service requires prior authorization: Please contact NovoLogix at 1-800-284-9229.
  • 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®

Claims will deny if you file self-administered drugs under the medical benefit that should be filed under the pharmacy benefit with the following codes:

 

 Remittance Type  Code   Description 
 Electronic  204  This service/equipment/drug is not covered under the patient's current benefit plan. 
 Hardcopy  9381  This service requires prior authorization: Please contact NovoLogix at 1-800-284-9229.

More information about prior authorizations for medical specialty drugs through NovoLogix, to include training materials and drug lists, are available on our websites, www.SouthCarolinaBlues.com and www.BlueChoiceSC.com, in the Provider Education section. You may also contact Provider Education by using the Provider Education Contact Form or by calling 803-264-4730.