Specialty Drugs and Pharmacy Drugs
Specialty Drugs and Pharmacy Drugs
Here is where you’ll find all the information you need on our prescription drug coverage.
- View the Tiered Prescription Drug List (PDL). With this six-tier PDL, drugs aren’t tied to generic, preferred and non-preferred copayment levels. Some generic drugs and brands with no added value compared to more cost-effective options may be available at higher tiers.
- Some members with individual coverage remain on the three-tier “legacy” PDL that BlueChoice HealthPlan has used for many years. View the BlueChoice® PDL.
- The Covered Drug List applies to all remaining BlueChoice Affordable Care Act (ACA) members.
- 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.
- The Opioid Management Program consists of daily quantity limits specific to each covered opioid drug and prior authorization requirements for certain prescribing situations.
- 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 ACA requires most health plans to cover certain drugs at $0 cost to members.
How Patients Can Save Money
- Use a Network Pharmacy — For your patients to have coverage under their benefit plan, they should use one of the 66,000+ pharmacies in our network.
- Lifestyle Medication Discount Program — If your patients have pharmacy benefits through BlueChoice, some non-covered medications may be available to them at a discount.
- My Health Toolkit — Members can compare drug costs, locate a pharmacy, review their prescription drug histories and much more.
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, CVS Specialty, to have coverage under their pharmacy benefit. CVS Specialty is a division of CVS Health, an independent company that provides specialty pharmacy services on behalf of BlueChoice®. To get a patient set up, please contact CVS Specialty at 800-237-2767. Or providers can fax a prescription to 800-323-2445.
For specialty drugs billed under the pharmacy benefit, CVS Specialty will review prior authorization requests. Please contact them at 800-237-2767.
Look at our complete Specialty Drug List to find out which drugs are covered and which require prior authorization under the pharmacy benefit.
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/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. CVS/caremark is an independent company that administers pharmacy benefits on behalf of BlueCross and BlueChoice. 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.
- Site of Care: Some infused specialty medications commonly administered in physician offices and hospitals can be safely provided at home or an infusion suite.
Which drugs are included on the medical prior authorization and self-administered drug and site of care 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: