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Self-administered Specialty Drug Reminder: Hemophilia Drugs

May 2, 2013

In the April 2013 Blue Review , we included a reminder that Blue Cross and Blue Shield of Texas (BCBSTX) members are required to use their pharmacy benefit for U.S. FDA-approved self-administered specialty drugs (oral, topical and injectable) and obtain these medications through a pharmacy provider that is contracted to provide specialty pharmacy services.

Self-administered drugs should not be submitted on professional/ancillary electronic (ANSI 837P) or paper (CMS-1500) claims.  In addition, effective July 1, 2013, the following message will be returned on the electronic payment summary or provider claim summary to providers billing for self-administered drugs, including self-administered drugs for hemophilia: “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.”

Sample List of Hemophilia Brand Name Drugs*
Please note: This list is subject to change from time to time.
• Advate
• Alphanate
• Alphanate/Von Willebrand Factor Complex Human
• Alphanine SD
• Bebulin
• Bebulin VH
• Benefix
• Feiba NF
• Feiba VH Immuno
• Helixate FS
• Hemofil M
• Humate-P
• Koate-DVI
• Kogenate FS
• Kogenate FS Bio-Set
• Monoclate-P
• Mononine
• Novoseven
• Novoseven RT
• Profilnine SD
• Recombinate
• Refacto
• Xyntha
*Trademarks mentioned above are the property of their respective owners.

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 of the BCBSTX provider website.

Note: In accordance with their benefits, members may be required to use a preferred specialty pharmacy. Please call the number on the member’s ID card to verify coverage or for further assistance or clarification on the member’s benefits. 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 (877-627-6337) 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 (Prime), a pharmacy benefit management company.

Blue Cross and Blue Shield of Texas (BCBSTX) is a Division of Health Care Service Corporation (HCSC), a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

HCSC contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. HCSC, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime.