Self-administered Drugs: Requirement Reminders

July 9, 2012

For those medications that are self-administered, Blue Cross and Blue Shield of Texas (BCBSTX) members are required to use their pharmacy benefit and acquire the medication through a pharmacy provider. Self-administered drugs can include oral, topical and injectable products.

For your patients to receive benefit coverage, the covered self-administered drugs must be provided under their pharmacy benefit and not dispensed through the physician’s office.

In January 2013, BCBSTX is planning to implement a system edit that will deny services submitted on physician claims for self-administered drugs that are covered under the member’s prescription drug benefit. Denied service lines on the claim will receive the following message:  “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, a Specialty Pharmacy Program Drug List will be available in the Pharmacy Program/Specialty Pharmacy section of our website. This list will identify those drugs that are approved for self-administration and therefore covered under the patient’s pharmacy benefit.

As a reminder, Triessent Specialty Pharmacy is the preferred specialty pharmacy for most BCBSTX members. To obtain specialty medications through the Triessent Specialty Pharmacy Program:

   1.    Collect Patient and Insurance Information

Use the Triessent 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 866-203-6010

Triessent Specialty Pharmacy’s team of pharmacists and benefit specialists will handle the details, from checking eligibility to coordinating delivery.

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. Regardless of benefits, the final decision about any medication is between the member and their health care provider.