Specialty medications are used to treat serious or chronic conditions such as multiple sclerosis, hemophilia, hepatitis C, and rheumatoid arthritis. These medications are typically injectable and can be administered by the patient or a family member. One or more of the following may also be true about these medications:
- They are injected or infused, but some may be taken by mouth
- They have unique storage or shipment requirements
- Additional education and support is required from a health care professional
- They are usually not stocked at retail pharmacies
All specialty medications require prior authorization/ preauthorization. BCBSOK members may be required to use contracted specialty network pharmacies to fill their prescription per their benefit plan. The pharmacists, nurses, and care coordinators in our specialty network pharmacies are experts in supplying medications and services to patients with complex health conditions. For those medications that are FDA-approved for self-administration, BCBSOK members are required to use their pharmacy benefit and acquire the medication through the appropriate pharmacy provider and not through the physician’s office. Self-administered drugs can include oral, topical and injectable products.
BlueLincs HMO members must use an in network Specialty Pharmacy to be eligible for benefits. If an in network pharmacy is not available, an out of network referral will be required. PPO members will receive their maximum benefits by utilizing an in network Specialty Pharmacy.
If services are submitted on professional/ancillary electronic (ANSI 837P) or paper (CMS-1500) claims for drugs that are FDA-approved for self-administration and covered under the member's prescription drug benefit, BCBSOK will notify the provider that these claims need to be re-filed through the member’s pharmacy benefit. In this situation, the following message will be returned on the electronic payment summary or provider claim summary: "Self-administered drugs submitted by a medical professional provider are not within the member's medical benefits. These charges must be billed and submitted by a pharmacy provider."
A Specialty Pharmacy Program Drug List is available to help you determine the correct path for medication fulfillment and ensure that the correct benefit is applied. This list will identify those drugs that are approved for self-administration and therefore covered under the patient’s pharmacy benefit.
AbbVie Endocrinology Inc. (AEI), doing business as Pharmacy Solutions, is a medical provider of Lupron Depot. To contact Pharmacy Solutions, call 800-859-0220.
The benefits of obtaining self-injectable specialty medications from these preferred specialty pharmacies include:
- Integrated coordination of coverage between the member, physician and BCBSOK
- No up-front acquisition cost to physicians for non-self-administered/office based specialty medications
- Convenient delivery of medication to physician's office or member's address
- Injection supplies with every shipment, including alcohol swabs, needles and syringes
- Automatic coordination of refills
- Patient education materials and therapy starter kits from drug manufacturers
- 24-hour hotline staffed nurse and/or pharmacist to call with medication and injection questions
Note: Injectable coverage is based on the member's benefit. Prior Authorization or Predetermination approval still applies to specific medications that fall under clinical review.
Prime Specialty Pharmacy is the preferred specialty pharmacy for most BCBSOK members. Please check the member’s ID card to confirm the member’s pharmacy provider. With a full inventory of specialty medications in stock and pharmacists available by phone 24/7, Prime Specialty Pharmacy also provides alerts for patient non-adherence issues, coordination of medication refills, information on patient assistance organizations and other support services.
To obtain specialty medications through the Prime Specialty Pharmacy program, follow these steps:
- Collect Patient and Insurance Information – Use the Prime Specialty Pharmacy fax form or your own prescription form, along with your office’s fax cover sheet. Be sure to include the physician’s signature and any clinical data that may support the approval process.
- Fax Signed Forms to 877-828-3939 – Prime Specialty Pharmacy’s team of pharmacists and benefit specialists will handle the details, from checking eligibility to coordinating delivery.
Prime Specialty Pharmacy provides safe and efficient delivery of specialty medications and integrated management across medical and pharmacy benefits. As a service to your patients, Prime Specialty Pharmacy can deliver those drugs that are approved for self-administration directly to the patient’s home or alternate location. Please note that Prime is also available for those specialty medications that are covered under the member’s medical benefit. For more information, contact Prime Specialty Pharmacy at 877-627-MEDS (6337). All required forms can be downloaded from the BCBSOK provider website.
Prime Therapeutics LLC is a pharmacy benefit management company. BCBSOK contracts with Prime Therapeutics, a separate company, to provide pharmacy benefit management and other related services. BCBSOK, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics LLC.
Prime Therapeutics Specialty Pharmacy LLC (Prime Specialty Pharmacy) is a wholly owned subsidiary of Prime Therapeutics LLC, a pharmacy benefit management company. Prime Therapeutics LLC is a partially-owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an independent licensee of the Blue Cross and Blue Shield Association. BCBSOK is a Division of HCSC, which contracts with Prime Therapeutics LLC to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services.
The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are instructed to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms set forth in the member's certificate of coverage which may vary from the limits set forth above. The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.