Pharmacy Optimization Initiative Highlights – 2nd Quarter 2014

August 11, 2014

Blue Cross and Blue Shield of Oklahoma (BCBSOK) is continuing to make enhancements to help improve the pharmacy program services and support we make available to you and your patients. Our 2nd quarter summary spotlights recent pharmacy initiatives, previews of upcoming topics and provides helpful reminders with links to related resources.

2nd Quarter 2014 Highlights

GuidedHealth® Program Updates

BCBSOK uses the GuidedHealth clinical rules platform to help monitor and promote appropriate use, safety and cost effectiveness of medications prescribed to our members. Informational letters are sent to providers regarding patients who may have potential drug therapy issues, as identified based on BCBSOK claims data. The member may also receive a letter.

  • In the first quarter 2014, letters were sent regarding potential underutilization* in the following areas: statin use in diabetics, ACE/ARB/RI use in diabetics, and inhaled corticosteroids use in asthma.
  • In the second quarter 2014, letters were sent related to potential overutilization in the following areas: off label use and stimulant polypharmacy.

Medication Adherence Program News

Recently, BCBSOK announced the transition of our medication adherence programs for cholesterol and diabetes to the GuidedHealth platform. In late June 2014, educational letters were sent to members identified as potentially non-adherent to their prescribed drug regimens for these programs, as well as from the following therapeutic areas: depression, HIV/antiviral and hypertension. If you have a patient identified in one of these programs, you also may have received an educational letter. For details, view the article titled, "Medication Adherence Program Moves to GuidedHealth Platform" in our June Blue Review .

Educational Resources to Assist You with Using CoverMyMeds®

Earlier this year, we announced the availability of CoverMyMeds for electronic submission of prescription drug benefit prior authorization (PA) requests. General/non-payer-specific educational resources are available on the CoverMyMeds site, such as online demonstrations of the tool, user guides, a Live Chat feature and more. Refer to the article in our June Blue Review  titled, "Save Time on Prescription Drug Benefit Prior Authorization (PA) Requests" for additional information.

3rd Quarter 2014 Preview

Controlled Substance Clinical Review Enhancements

Our controlled substance clinical review program includes new criteria to help better identify members with medication utilization patterns that may indicate potential abuse, misuse or improper utilization. BCBSOK care management teams will collaborate to increase awareness and develop action plans to support appropriate utilization, as well as coordination of care for complex cases. These enhancements were announced in the July Blue Review  in an article titled, "Supporting Appropriate Use of Prescribed Controlled Substance Medications."

Reminders & Helpful Resources

Billing with National Drug Codes (NDCs)

When you bill with NDCs, in addition to including the appropriate HCPCS or Current Procedural Terminology (CPT®) information, BCBSOK can identify and reimburse your office, in most instances, for the individual medication that was prescribed.

Select Medication List

NDC pricing has paved the way for other initiatives, such as our Select Medication List, which will be developed in stages to add specific drugs within particular classes or categories, based on safety and cost effectiveness. View the current BCBSOK Select Medication List  for details.

General Information

Visit the Pharmacy Program section for information on drug formularies, dispensing limits, prior authorization/step therapy, specialty pharmacy and more. Also continue to watch our News and Updates and monthly Blue Review newsletter for details.

* Underutilization may align with gaps in care and medication adherence. If a member is targeted as an underutilizer, then they are likely not taking their medications as frequently as prescribed, or are non-adherent. Gaps in care would include situations where a member has a condition that requires drug therapy and the physician has not included this therapy in the member's drug regimen. Educational information is sent to help increase awareness and support patient safety in these scenarios.

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. Not all programs may be available to HMO members. 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.

GuidedHealth is a registered trademark of Prime Therapeutics LLC (Prime), a pharmacy benefit management company. BCBSOK contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSOK, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. BCBSOK makes no endorsement, representations or warranties regarding GuidedHealth. If you have any questions about this product or services, you should contact Prime Therapeutics LLC directly.

CoverMyMeds is a registered trademark of CoverMyMeds LLC, an independent third party vendor that is solely responsible its products and services.

CPT copyright 2013 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.