Specialty Drug Benefit Changes Effective October 1, 2017

Specialty Drug Benefit Changes Effective Oct. 1, 2017

8/8/2017

Preferred Drugs
Effective Oct. 1, 2017, BlueCross BlueShield of South Carolina and BlueChoice® HealthPlan will implement a new preferred drug strategy to more effectively manage specialty drugs billed under the medical benefit. The following specialty drugs will be classified as preferred or non-preferred under the medical benefit. At this time, only the below drugs will be impacted. More will be added at a later date.

 
Conditions Treated  Preferred Products  Non-Preferred Products 

Anti-Inflammatory Conditions
(i.e., Rheumatoid Arthritis,
Psoriasis, Crohn's) 
  • Orencia
  • Remicade
  • Simponi Aria
  • Actemra
  • Cimzia
  • Entyvio
  • Inflectra
  • Stelara

Hemophilia
  • Kogenate FS 
  •  Helixate FS

Neutropenia
(Colony Stimulating Factors)
  • Zarxio 
  • Neupogen
  • Granix
  • Leukine 
What you need to know:
  • Non-preferred products are only available if criteria are met or the member has received trial and failure of preferred products.
  • This strategy will impact groups that have implemented the medical prior authorization program through NovoLogix, a CVS/Caremark online prior authorization tool. Novologix is 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.
  • This strategy applies to members that are new to therapy and current users when their current prior authorization expires. 
  • Our members have received communication regarding this implementation.
 

Self-Administered Drugs
Effective Oct. 1, 2017, some intravenous immunoglobulin (IVIG) drugs will be added to the Self-Administered Drug list and must be filled under the pharmacy benefit. This means that these drugs will not be covered under the medical benefit (except in an inpatient hospital setting). 

Below are the drugs that will be added to the Self-Administered Drug List:

 
Bivigam Carimune Carimune NF Cytogam
Flebogamma Flebogamma DIF GamaSTAN SD Gammagard liquid
Gammagard S/D Gammaked Gammaplex Gamunex
Gamunex-C Hepagam B Hizentra HyperHep B
Hyqvia Octagam Panglobulin NF Privigen

What you need to know:
Oncologists, hematologists, nephrologists and rheumatologists will be exempt from the self-administered drug block and can continue to bill these drugs under the medical benefit.
Our members have received communication regarding this implementation.

Medical Prior Authorization
As of Oct. 1, 2017, the drug Avastin will require prior authorization through Novologix when used as chemotherapy.

 

What you need to know:

  • Members with current Avastin PAs will not be required to get a new one until their existing one expires.
  • Our members have received communication informing them of the new prior authorization requirement.
If you have questions about this bulletin, please send an email to provider.education@bcbssc.com or submit your question using the Provider Education Contact Form. As additional information, our members received notices regarding these pharmacy benefit changes.