Specialty Drugs and Pharmacy Drugs

  • Prescription Drugs

    Here is where you’ll find all the information you need on our prescription drug coverage.

    Drug Lists

    • Some members need prior authorization for certain drugs.
    • The Quantity Management program limits the amount of certain drugs a plan will cover.
    • The Step Therapy program helps ensure quality, cost-effective drug therapy. View the list of drugs under this program.
    • Excluded Drug List — This is a list of drugs that are excluded from coverage. The document also includes information on how to request a formulary exception for an excluded drug.
    • $0 Covered Drug List — Under Health Care Reform, the Affordable Care Act (ACA) requires most health plans to cover certain drugs at $0 cost to members.

     

    Prior Authorization

    CoverMyMeds

    Our pharmacy benefit manager has partnered with CoverMyMeds to offer free electronic prior authorization (ePA) services to all providers and their staff. ePA helps prescribers and pharmacies quickly find, complete and submit prior authorization (PA) requests.

    You can use CoverMyMeds to:

    • Submit the request electronically.
    • Quickly find the correct PA request form for your patient’s plan.
    • Receive real-time plan specific clinical guideline questions (where applicable).
    • Complete PA requests started by pharmacies.
    • Easily manage follow-ups for all your requests and patients.
    • Check status of ePA requests submitted.

    To get started all you need to do is register for a free account or log into your existing CoverMyMeds account.

    Create an account by:

    • Clicking on the “Get Started” red button.
    • Filling out required basic account information (name, email, office type, username and password).

    View the demonstration for more details.

    Our pharmacy benefit manager also accepts prior authorizations via phone and fax.

  • Specialty Pharmacy Drugs

    BlueChoice HealthPlan provides coverage for specialty drugs under both the pharmacy and medical benefit. Members must fill oral and self-injectable medications through our preferred specialty pharmacy to have coverage under their pharmacy benefit. To get a patient set up, please call 877-259-9428.

    Prior Authorization

    CoverMyMeds

    Our pharmacy benefit manager has partnered with CoverMyMeds to offer free electronic prior authorization (ePA) services to all providers and their staff. ePA helps prescribers and pharmacies quickly find, complete and submit prior authorization (PA) requests.

    You can use CoverMyMeds to:

    • Submit the request electronically.
    • Quickly find the correct PA request form for your patient’s plan.
    • Receive real-time plan specific clinical guideline questions (where applicable).
    • Complete PA requests started by pharmacies.
    • Easily manage follow-ups for all your requests and patients.
    • Check status of ePA requests submitted.

    To get started all you need to do is register for a free account or log into your existing CoverMyMeds account.

    Create an account by:

    • Clicking on the “Get Started” red button.
    • Filling out required basic account information (name, email, office type, username and password).

    View the demonstration for more details.

    Our pharmacy benefit manager also accepts prior authorizations via phone and fax.

  • Specialty Medical Drugs

    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 or infusible) specialty drugs will require prior authorization. In addition, some infused specialty medications commonly administered in physician offices and hospitals will only be authorized to be provided in approved sites of care, such as at home or an infusion suite.
    • 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 specialty drug lists?

    Please see these 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.

     

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