Pharmacy Optimization Initiative Highlights – 1st Quarter 2014

April 11, 2014

Our pharmacy program initiatives continue to help improve the services we make available to you and your patients. To help you keep up with the latest news, we'll be posting a summary at the end of each quarter. Each quarterly update will spotlight recent enhancements, tools and programs, along with links to articles and resources you may have missed.

Here are some highlights from the 1st Quarter 2014:


Self-administered Specialty Drug Updates

In 2013, Blue Cross and Blue Shield of Texas (BCBSTX) expanded its claims processing system to automatically redirect professional electronic (837P) and paper (CMS-1500) claims to help ensure application of correct benefits for drugs approved by the U.S. Food and Drug Administration for self-administration. As of Jan. 1, 2014, the last "wave" of system edits was implemented for fertility, oral oncology, and various other select self-administered specialty drugs. Details were published in an article titled, Self-Administered Specialty Drug Claim Processing Reminder, which appears on page 5 of our January Blue Review pdf.

GuidedHealth®' Program Updates

BCBSTX uses the GuidedHealth clinical rules platform to help monitor and promote appropriate use, safety and cost effectiveness of medications prescribed to our members. Patients with potential drug therapy issues may be identified based on claims data. Articles are published in the Blue Review to help keep you informed about areas of focus. For a listing of programs implemented in third quarter 2013, as well as an update on action you may need to take if you receive a letter, refer to the article titled GuidedHealth Helps Identify Drug Therapy Opportunities, which appears on page 4 of our January Blue Review pdf.

National Drug Code (NDC) Pricing Reminders & Resources

Many resources are available to assist you when billing with NDCs on medical claims, such as our NDC Billing Guidelines pdf and Frequently Asked Questions pdf. There's also an NDC Billing Tutorial and an NDC Units Calculator Tool available to contracted providers on the Availity®'' provider portal at . We've also published a number of reminder articles, based on feedback from providers. For example, while you may know that, if you bill for drugs on medical claims, the NDC must be valid for the date of service, otherwise correct reimbursement cannot be applied. To help guard against inadvertent use of inactive and obsolete NDCs, see page 8 of our January Blue Review pdf for an article titled, Quick Tip: Check Your Records for Outdated Drug Codes.


Electronic Tools for Prescription Drug Benefit Prior Authorization (PA) Requests

BCBSTX continues to enhance the process for submitting PA requests. Refer to page 1 of our March Blue Review pdf for the article titled, Electronic Options for Pharmacy Prior Authorization (PA) Requests to learn more about how online tools such as iEXCHANGE® can replace the need to fax paper forms, resubmit requests or call to check status of your request. This article focuses on iEXCHANGE, which includes electronic PA forms for specific drugs that may be considered for coverage under the medical benefit. The article also offers reminders on CoverMyMeds®''' , a tool for PA requests for drugs that may be considered for coverage under the member's pharmacy benefit.


Visit the Pharmacy Program section for information on our Standard Preferred Drug List, step therapy/prior authorization, specialty drug programs and more. Also continue to watch for updates in our monthly Blue Review.

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 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.

GuidedHealth is a registered trademark of Prime Therapeutics LLC (Prime), a pharmacy benefit management company. BCBSTX contracts with Prime 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. BCBSTX makes no endorsement, representations or warranties regarding GuidedHealth. If you have any questions about this product or services, you should contact Prime Therapeutics LLC directly.

Availity is a registered trademark of Availity, LLC. Availity is a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors. If you have any questions about the products or services offered by such vendors, you should contact the vendors directly.

CoverMyMeds is a registered trademark of CoverMyMeds LLC, an independent third party vendor that is solely responsible its products and services.