System Edit for Self-Administered Specialty Drugs
RE: Services Billed on Professional/Ancillary (837P and CMS-1500) Claims
For medications that are approved by the U.S. Food and Drug Administration (FDA) for self-administration, Blue Cross and Blue Shield of Texas (BCBSTX) members are required to use their pharmacy benefit and acquire self-administered drugs (oral, topical and injectable) through a pharmacy provider. Self-administered drugs must be billed under the member’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 FDA-approved for self-administration and covered under the member’s prescription drug benefit, BCBSTX 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.”
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 in the Pharmacy Program/Specialty Drug Programs section.
Note: The member’s benefits may require the use of a preferred specialty pharmacy to receive in-network benefits. Please call the number on the member’s ID card to verify coverage restrictions. For member’s whose benefits require them to use Prime Therapeutics Specialty Pharmacy, you may fax the prescription to 877-828-3939 or call 877-627-MEDS (6337) for additional information. Medication(s) can be delivered to any requested location (e.g., member’s home or physician’s office).
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.
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 to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSTX, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.