Provider Roles And Responsibilities Basic 112 Ppo Secg

User Manual: Basic 112

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Blue Choice PPOSM Provider Manual Pharmacy
In this

The following topics are covered in this section.




Pharmacy Network


Drug List Evaluation


Drug List Updates


Generic Drugs


Drug Utilization Review (DUR) Overview


Covered Pharmacy Services


Non-Covered Pharmacy Services


Drugs Requiring Preauthorization


Specialty Pharmacy Program and Specialty Pharmacy Network


Are You a Provider Billing for Compound Drugs?

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Are You a Provider Billing Unlisted J-Codes?

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A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Updated 12-22-2016

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Blue Choice PPO Provider Manual Pharmacy

The following applies to subscribers who have a Blue Cross and
Blue Shield of Texas (BCBSTX) Prescription Drug Rider. Depending
on the subscriber’s individual contract, pharmacy services may or
may not be provided through the BCBSTX pharmacy plan. Some
plans may be “carved out” to other Pharmacy Benefit Managers
(PBMs). BCBSTX’s PBM name is listed on the front of the
subscriber’s identification card. Prime Therapeutics is the PBM that
provides drug benefits through BCBSTX.


BCBSTX members with a “pharmacy card” prescription drug
benefit must use a pharmacy on the approved list of participating
pharmacies. This pharmacy network can include retail for up to a
30-day supply or 90-day supply, mail-order for up to a 90-day
supply or specialty pharmacy for up to a 30-day supply. Some
members’ pharmacy benefit plans may include an additional
preferred pharmacy network, which offers reduced out-of-pocket
expenses to the member if they use one of these pharmacies
instead. Please encourage your patients to use one pharmacy for
all of their prescriptions to better monitor drug therapy and avoid
potential drug-related problems.
BCBSTX contracts for mail-order pharmacy services to augment
our retail pharmacy network. Members of our plans may receive up
to a 90-day supply of maintenance medication (e.g., drugs for
arthritis, depression, diabetes, or hypercholesteremia) through the
home delivery pharmacy service. If you believe that a member of
one of our plans will continue on the same drug and dose for an
indefinite period of time, please consider writing the prescription
for a 90-day supply with three refills. If the patient is starting a
new medication for the first time, you should write two
prescriptions. One for up to a 90-day supply with three refills and
a starter supply for up to 30 days that the patient can fill right
away at the local retail pharmacy.
Specialty drugs that are FDA approved for patient selfadministration typically are acquired through a specialty pharmacy
provider. The patient may also bill these drugs under their

pharmacy benefit to receive maximum coverage.
Drug List

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BCBSTX uses the Prime Therapeutics National Pharmacy and
Therapeutics (P&T) Committee, which is responsible for drug
evaluation. The P&T Committee consists of independent practicing
physicians and pharmacists from throughout the country who are
not employees or agents of Prime Therapeutics. BCBSTX will have
one voting subscriber on the committee. The P&T Committee meets
quarterly to review new drugs and Updated 12-22-2016 drug
information based on the current available literature.

Updated 12-22-2016

Blue Choice PPO Provider Manual Pharmacy
Drug List

BCBSTX delegates RX utilization management services to Prime
Therapeutics for prior authorizations, quantity exceptions, and/or
step therapy for members who have a BCBSTX Prescription Drug
Rider. To request a prior authorization, go to the Prior
Authorization and Step Therapy Program information at\provider. We have established committees which
determine the addition of brand-name drug products to the
Prescription Drug List (also known as a formulary).

Drug List

BCBSTX provides notification to physicians of additions and
changes made to the BCBSTX Prescription Drug List Guide by
newsletters and on the BCBSTX Provider website. Members may
be notified of changes by direct mailings. Additions and updates
to the Drug List can be found on the\provider website
under the Pharmacy Program tab.
Members who are identified as taking a medication that has
been deleted from the BCBSTX Prescription Drug List are sent a
letter detailing the change at least 60 days prior to the effective
deletion date. It is important to remember that a medication
deleted from the BCBSTX Prescription Drug List may still be
available to subscribers yet at a higher copayment or the
medication may not be covered and the subscriber is charged for
the full amount of the drug cost.
BCBSTX and Prime Therapeutics also provide pharmaceutical
safety notifications to dispensing providers and subscribers
regarding point-of-dispensing drug-drug interaction and FDA drug

Updated 12-22-2016

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Blue Choice PPO Provider Manual Pharmacy

The Food and Drug Administration (FDA) has a process to assign
equivalency ratings to generic drugs. An “A” rating means that the drug
manufacturer has submitted documentation demonstrating equivalence
of its generic product compared to the brand name product.
BCBSTX supports the FDA process for determining equivalency and
strongly advises its contracted providers to prescribe drugs that have
generic alternatives available and not to add “dispense as written” to
prescriptions. Most plans may require subscribers to pay the
difference between the brand-name drug and generic drug plus the
generic copayment. For BCBSTX subscribers, the average difference
in cost between brand-name and generic drugs in 2014 was about
$360; a significant amount.


BCBSTX and Prime Therapeutics conducts concurrent and
retrospective drug utilization reviews to ensure the most
appropriate and cost-effective drugs are used safely.
Concurrent DUR occurs at the point of sale (i.e., at the dispensing
pharmacy). Pharmacies are electronically linked to Prime
Therapeutics’ claims adjudication system. This system contains
various edits that check for drug interactions, overutilization (i.e.,
early refill attempts), and therapeutic duplications. The system also
alerts the pharmacist when the prescribed drug may have an
adverse effect if used by elderly or pregnant subscribers. The
pharmacist can use his or her professional judgment and call the
prescribing provider if a potential adverse event may occur.
Retrospective DUR uses historical prescription and/or medical
claims data to identify potential prescribing and dispensing issues
after the prescription is filled. Examples of retrospective DUR
include appropriate use of controlled substances, adherence and
generic utilization programs. These programs aim to promote
safety, reduce overutilization and close gaps in care.
Retrospective DUR programs are developed based on widely
accepted national practice guidelines. Individual letters may be
mailed to providers identifying potential drug therapy concerns,
together with a profile listing the subscriber’s prescription
medications filled during the study period, references to national
practice guidelines and/or a link to an online survey to be

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Blue Choice PPO Provider Manual Pharmacy

The following is a list of typically* covered pharmacy services:
 Glucagon and anaphylactic kits
 Insulin, syringes, lancets, and test strips
 Unless specifically excluded (e.g., obesity, infertility, or cosmetic
drugs), any prescription drug, provided that the drug is ordered
by the member’s Primary Care Physician (PCP) or a physician to
whom the member has been referred.
 The member’s applicable prescription copayment will apply for
each prescription or refill for 30 days.
 Oral Contraceptives, limited to a 28-dayor one-month supply


 Preventive vaccinations ( e.g.influenza, TDAP, shingles etc
 One applicable copay will apply to most “packaged’ item (e.g.,
 Medications that are approved by the U.S. Food and Drug
Administration (FDA) for self-administration.
The following is a list of typically* non-covered pharmacy services:



Any charge for most therapeutic devices or appliances
(e.g.,support garments and other non-medical substances),
regardless of their intended use


Investigational use of medication


Medications specifically excluded from benefit (e.g., drugs used
for cosmetic purposes or for treatment of obesity)


Any drug which, as required under the Federal Food, Drug and
Cosmetic Act, does not bear the legend: “Caution: Federal law
prohibits dispensing without a prescription,” even if prescribed
by a physician (over-the-counter)


Drugs that have not received approval from the FDA


Nutritional supplements (coverage requires preauthorization)
Compound medications are not a covered benefit under most plans

 Prescriptions obtained at an out-of-network pharmacy, unless inan


Updated 12-22-2016

Note: Not all BCBSTX plans include pharmacy benefits. For BCBSTX plans with Pharmacy coverage,
verifying member's benefits is highly recommended as each policy may have unique benefits

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Blue Choice PPO Provider Manual Pharmacy

Drugs with a high potential for experimental or off-label use may
require preauthorization (also known as prior authorization). For
drugs that require a prior authorization, step therapy or quantity
limits, go to the BCBSTX Provider website and click on the
Pharmacy Program tab for detailed information, including links to
forms and program criteria summaries.
While physician fax forms are available, you can also submit the
request electronically via the CoverMyMeds® website. A link to
this site can be found on the BCBSTX Provider website. Changes
to these requirements are also published in our provider
newsletter, Blue Review. If you have any additional questions,
please call Prime Therapeutics at 800-289-1525.
BCBSTX allows for certain off-label uses of drugs when the offlabel uses meet the requirements of the BCBSTX policy.
For information about the PA medical criteria, please review our
Medical Policies in the Standards & Requirements section of our
BCBSTX Provider website.

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Blue Choice PPO Provider Manual Pharmacy


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 subscriber. One or
more of the following may also be true about these medications:
 They are injected or infused, but some may be taken orally
 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
Most specialty medications may require prior authorization/
preauthorization. Links to forms and program criteria
summaries can be found on the Prior Authorization/Step
Therapy section of our BCBSTX Provider website.
BCBSTX subscribers may be required to use contracted specialty
network pharmacies only to fill their prescription for coverage
consideration, 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 approved by the U.S. Food and
Drug Administration (FDA) for self-administration, BCBSTX
subscribers may be required to use their pharmacy benefit and
acquire self-administered drugs (oral, topical and injectable)
through the appropriate contracted pharmacy provider and not
through the physician’s office. Self-administered drugs should be
billed under the subscriber’s pharmacy benefit for your patients to
receive coverage.
If services are submitted on professional/ancillary electronic (ANSI
837P) or paper (CMS-1500) claims for drugs that are FDAapproved for self-administration and covered under the
subscriber’s prescription drug benefit, BCBSTX will notify the
provider that these claims need to be re-filed through the
subscriber’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 subscriber’s
medical benefits. These charges must be billed and submitted by a
pharmacy provider.”
If you have questions about the specialty program, a patient’s
benefit coverage and/or to ensure the correct benefit is applied for
medication fulfillment, please call the Customer Service number on
the back of your patient’s member ID card.
For information about medical criteria, please refer to the Medical
Policies information located on the BCBSTX Provider website.

Updated 12-22-2016

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Blue Choice PPO Provider Manual Pharmacy

Prime Specialty Pharmacy is the preferred specialty pharmacy for
most BCBSTX subscribers. Please check the subscriber’s ID card to
confirm the subscriber’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
To obtain specialty medications through the Prime Specialty Pharmacy
program, follow these steps:
1. 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.
2. 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 selfadministration 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 subscriber’s medical benefit.
For more information, visit the Pharmacy Program/Specialty Pharmacy
section of our website at or contact Prime
Specialty Pharmacy at 877-627-MEDS (6337).
BCBSTX contracts with select in-network specialty pharmacies* to
ensure the availability of specialty medications. In addition to Prime
Specialty Pharmacy, there are other specialty pharmacies available for
hemophilia (factor) products and outpatient and home infusion
services, as an example. For those subscribers who have Prime
Therapeutics (Prime) as their pharmacy benefit manager, acquiring
self-administered specialty drugs through these specialty pharmacies
will help to ensure maximum benefit coverage.
For a complete list of all in-network specialty pharmacies, please visit
the Pharmacy Program/Specialty Pharmacy section of our website at
*The relationship between BCBSTX and the specialty pharmacies is that of
independent contractors

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Blue Choice PPO Provider Manual Pharmacy
Are You a
Billing for

Drug compounding is the process of mixing, combining, or alternating
ingredients to create a customized medication. This is considered
experimental, investigational and unproven in most cases according to
the Blue Cross and Blue Shield of Texas (BCBSTX) Medical Policy on
Compounded Drugs.
The properties of certain drugs may be altered and combined by a
compounding pharmacy to create a customized medication for the use
in a pain pump or for progesterone therapy as a technique to reduce
preterm delivery in high-risk pregnancies. Please review the following
Blue Cross and Blue Shield of Texas Medical Policies related to
Progesterone Therapy (RX501.062) and Implantable Infusion Pumps
(SUR707.008) by going to and clicking on the
Standards & Requirements tab.
Compound drugs should be filed under the appropriate “Not Otherwise
Classified” procedure code with the Modifier KD.
BCBSTX has adopted the same methodology as the Centers for
Medicare and Medicaid Services (CMS).
Under the Standards & Requirements tab, please visit our General
Reimbursement Information area on our provider website at You will be directed to enter the password and
agree to our Policies Disclaimer notice. Click on Compound Drug
Schedules located under Reimbursement Schedules & Related
Information section.
If you have any questions, please contact Provider Customer Service
at 800-451-0287 to speak with a Customer Advocate.

Updated 12-22-2016

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Blue Choice PPO Provider Manual Pharmacy
Are You a
Unlisted JCodes?

Did you know more than 50% of National Drug Code (NDC)
numbers have either an assigned Current Procedural Terminology
(CPT) code or an assigned Healthcare Common Procedure Coding
System (HCPCS) code?
CPT codes are referred to as Level I codes and are maintained by
the American Medical Association (AMA). Level I codes are
comprised of five (5) characters in length and are numerical (e.g.
99211, 30520, etc.).
HCPCS codes are referred to as Level II codes and are governed by
the American Hospital Association (AHA) and the Center for
Medicare and Medicaid Services (CMS). Level II codes are five (5)
characters in length and are comprised of one (1) letter and four
(4) numbers (e.g. J1950, J9217, etc.).
In most instances, NDC numbers are assigned a CPT or HCPCS
code. Most injectable medications begin with a “J”, but this is not
always the case. It is important that claims be submitted with the
most accurate information when billing for injectable medications
that are administered in the office during a patient’s visit.
In an effort to ensure providers are billing appropriately and are
being reimbursed properly, Blue Cross and Blue Shield of Texas
(BCBSTX) checks the NDC numbers billed with an unlisted J-Code
to ensure these codes are being billed correctly.
What does this mean for our providers?
 If a claim is submitted using an unlisted J-Code (e.g. J3490)

and a valid CPT/HCPCS code exists for the drug being
administered, BCBSTX will deny the service line and request
the provider to resubmit using the correct CPT/HCPCS code.
 If a claim is submitted with an unlisted J-Code (e.g. J3490)
and there is no other CPT/HCPCS code for the drug being
administered, the provider will need to provide the necessary
information on the claim for BCBSTX to properly adjudicate
the service line. If the claim is received without the
necessary information, the service line may be denied and
sent back to the provider with a request to resubmit the
service along with the necessary information.

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Blue Choice PPO Provider Manual Pharmacy
Are You a
Unlisted JCodes?

o Necessary information needed to process valid unlisted J-Codes:




NDC Number
Drug Name
Dosage administered (e.g. 5 mg, 10 mg, etc.) Include
how the number of units being billed on the claim is being
administered (e.g. 5 mg = 1 unit, 10 mg = 5 units, etc.)
Strength of drug administered (e.g. 25 mg/ml, 10 mg/10
ml, etc.)
Single dose vial or Multi-dose vial

Please Note: An NDC number will be reimbursed for a maximum
of two (2) years after it becomes obsolete.
For additional information, refer to the NDC Billing Guidelines and
NDC Billing Frequently Asked Questions, located in the Claims and
Eligibility/Submitting Claims section of our BCBSTX Provider
If you have any questions, you may contact our Provider
Customer Service Department at 800-451-0287 to speak with a
Customer Advocate for assistance.

All required forms can be downloaded from the BCBSTX Provider
website. The forms are located in the Education & Reference section
of this website.

CoverMyMeds is a registered trademark of CoverMyMeds LLC, an independent third party vendor that is solely responsible for its products and services. BCBSTX
makes no endorsement, representation or warranties regarding any products or services offered by independent third party vendors. If you have any questions
regarding the products or services they offer, you should contact the vendor(s) directly.
CPT copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA
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 subscriber’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.Subscribers 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 subscriber
and their health care provider.
Prime Therapeutics Specialty Pharmacy LLC (Prime Specialty Pharmacy) is a wholly owned subsidiary of Prime Therapeutics LLC, a pharmacy benefit management
company. BCBSTX contracts with Prime Therapeutics LLC to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services.
BCBSTX, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime.

Updated 12-22-2016

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