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1 mar, 2021

Drugs moving from the specialty pharmacy benefit to the medical benefit 4/1/21

As part of our ongoing efforts to make high-quality and affordable healthcare available to our members, BCBSRI regularly reviews the list of prescription drugs we cover. Our goal is to make sure that our members continue to have access to effective medications.

As a result, effective 1 de abril de 2021, the drugs listed below will move from the specialty pharmacy benefit to the medical benefit. Some of these drugs will continue to require prior authorization (PA) under the BCBSRI Medical Drug Review (MDR) program administered by Prime Therapeutics, LLC, our pharmacy benefits manager. If your patient currently has an existing prior authorization for the medication, no additional prior authorization is required. For members receiving home infusion services, a new prescription will be needed and should be sent directly to the home infusion provider.

As with other drugs covered under the medical benefit, the drugs below will be eligible for buy and bill effective 1 de abril de 2021. They will not be required to be obtained from AllianceRx, Walgreens Specialty Pharmacy. When billing for any of these drugs, please provide the appropriate HCPC code included in the attached drug list. Administration codes will be required as previously utilized.

Brand

HCPC

Actemra IV     J3262

Botox             J0585

Dysport         J0586

Eylea            J0178

Lucentis       J2778

Lupron Depot/Eligard       J9217

Lupron Depot pedi           J1950

Prolia/Xgeva                    J0897

Rituxan                            J9312

Ruxience                        Q5119

Simponi Aria                   J1602

Trelstar                          J3315

Truxima                        Q5115

Tysabri                         J2323

Visudyne                      J3396

 Xeomin                       J0588

Xoladex                        J9202
 

BCBSRI members currently receiving these medications will be notified of this upcoming change. We are recommending that our members affected by these changes discuss their medication treatment options with their provider to determine whether their medications are still right for them. If you would like a copy of your members that are currently receiving any of the medications listed above, please contact Provider Relations at providerrelations@bcbsri.org.

As a reminder, you may obtain prior authorization through one of the following three methods:

Electronic prior authorization (ePA)

CoverMyMeds is the ePA tool offered through BCBSRI and Prime Therapeutics. Using CoverMyMeds allows for electronic submission of prior authorizations for any prescription drug. When you submit prior authorizations electronically, they are seamlessly integrated with your electronic health record system, offering you ePA functionality right in your office. Some of the benefits include:

 

Prior authorization by fax

You can fax the prior authorization form to 1-855-212-8110

 

Prior authorization by mail

Send your PA form to:

Prime Therapeutics, LLC

Attn.: Clinical Review Dept.

1305 Corporate Center Dr.

Eagan, MN 55121

 

For other questions, please contact your Provider Relations Representative, or contact Provider Relations at 1-844-707-5627 or providerrelations@bcsri.org.

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