Process Reminders for Self-administered Drugs

November 22, 2012

For those medications that are approved by the U.S. Food and Drug Administration (FDA) for self-administration, Blue Cross and Blue Shield of Oklahoma (BCBSOK) members are required to use their pharmacy benefit and acquire the medication through a pharmacy benefit provider. For your patients to receive benefit coverage, the covered self-administered drugs must not be dispensed through the physician’s office or a Home Infusion Therapy (HIT) Ancillary provider (where the HIT Ancillary provider is shipping drugs to a member’s home for self-administration).

As a reminder, effective Jan. 1, 2013, BCBSOK will implement a system edit that will deny services submitted on professional electronic (ANSI 837P) and paper (CMS-1500) claims for drugs that are FDA-approved for self-administration and that are covered under the member’s prescription drug benefit. Denied service lines on the claim will receive the following message:  “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.”

To help you determine the correct path for medication fulfillment and ensure that the correct benefit is applied, please refer to the Specialty Pharmacy Program Drug List  – it identifies those drugs that are approved for self-administration and therefore covered under the patient’s pharmacy benefit.

Please continue to watch the Blue Review, as well as the News and Updates section of our Provider website for additional announcements on BCBSOK programs, announcements and initiatives.

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.