Prime Therapeutics Provider‑Administered Specialty Pharmacy Drug List (PEEHIP exceptions noted)
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List of provider‑administered specialty medications managed by Prime Therapeutics for Blue Cross and Blue Shield of Alabama members, including prior‑authorization indicators, limited distribution flags, and specialty pharmacy billing guidance. Affects providers and specialty pharmacies administering or billing these drugs for BCBS‑Alabama members (PEEHIP exceptions noted).
No material clinical or coverage changes in this revision.
Coverage criteria and scope
For PEEHIP members, provider‑administered medications listed on the Prime Therapeutics Provider‑Administered Specialty Pharmacy Drug List are excluded from access through a specialty pharmacy and must be obtained via buy and bill, except where specifically noted. The named exceptions are Lemtrada (requires specialty pharmacy), and Synagis and Spravato (may be obtained either via buy and bill or through a specialty pharmacy).
To receive in‑network benefits when a specialty pharmacy files the claim, that specialty pharmacy must be contracted with the Blue Cross and Blue Shield plan where the provider is located. The in‑network specialty pharmacies identified in the list include Accredo Health Group, Inc. and CVS/Caremark; providers should check member benefits for the complete list of in‑network pharmacies.
Provider requirements and action items
PEEHIP specialty pharmacy / buy‑and‑bill exception
For PEEHIP members: provider‑administered medications listed on this specialty pharmacy drug list are excluded from being filled through a specialty pharmacy and must be obtained via buy‑and‑bill, except for Lemtrada, Synagis, and Spravato. Lemtrada must be obtained through a specialty pharmacy; Synagis and Spravato may be obtained either via buy‑and‑bill or specialty pharmacy.
- Affected drugs: provider‑administered medications listed on the Specialty Pharmacy Drug List
- Exceptions: Lemtrada (specialty pharmacy required); Synagis and Spravato (either route)
Prior Authorization Required
Drugs marked (PA) on the list require prior authorization before they will be covered. Ensure prior authorization is obtained and approved before billing.
- (PA) indicator appears next to specific drug names on the list — prior authorization must be secured prior to claim submission
- Obtain all required clinical documentation per payer guidelines when requesting PA
In‑network specialty pharmacy requirement
The specialty pharmacy filing the claim must be contracted with the member's Blue Cross and Blue Shield plan in order for the member to receive in‑network specialty pharmacy benefits. Confirm the specialty pharmacy is in‑network before having claims filed.
- In‑network specialty pharmacies referenced: Accredo Health Group, Inc.; CVS/Caremark — verify current in‑network status and member benefits list before claim submission
- If the specialty pharmacy is out‑of‑network, in‑network benefit levels may not apply
Payment not guaranteed
Listing a drug on this document or successful adjudication of a pharmacy claim does not guarantee payment. Claims may still be denied for other reasons.
- Treat this list as subject to change without notice
- Successful adjudication or inclusion on the list is not a guarantee of payment — follow payer billing rules and confirm benefits
Key definitions
Step therapy and sequencing
| Step | Requirement / Note |
|---|---|
| 1 | No step‑therapy sequencing is specified in this document; only prior authorization (PA) and limited distribution (*) indicators are provided. Refer to the policy key where (PA) = requires prior authorization and * = limited distribution. |
| 2 | Drugs marked with (PA) require prior authorization before coverage/billing. |
| 3 | Limited distribution drugs (marked with *) are distributed through select pharmacies due to special dosing or monitoring requirements; manufacturer or FDA may limit distribution. |
| 4 | For drugs that require in‑network specialty pharmacy billing (notation in key), the medication must be obtained and billed by an in‑network medical specialty pharmacy as indicated in the policy key. |
Site-of-care and billing location guidance
Specialty pharmacy must be in‑network
A specialty pharmacy must be contracted with the Blue plan where the provider is located in order for the member to receive in‑network benefits.
- Named in-network specialty pharmacies: Accredo Health Group, Inc. and CVS/Caremark.
PEEHIP buy-and-bill requirements and Lemtrada exception
For PEEHIP members most provider-administered medications must be obtained via buy and bill; Lemtrada is an exception requiring a specialty pharmacy, while Synagis and Spravato may be obtained either by buy and bill or through a specialty pharmacy.
Background and clinical context
Specialty medications are high‑cost therapies generally used for complex or chronic conditions such as multiple sclerosis, hemophilia, hepatitis C, and rheumatoid arthritis. They frequently require injection or infusion (though some are oral), have unique storage or shipment requirements, and often require additional provider education and support.
Because of those characteristics, these drugs are commonly managed through specialty distribution channels and have distinct billing and site‑of‑care considerations. For PEEHIP members this policy clarifies that most provider‑administered specialty drugs must be obtained through buy and bill, with limited exceptions noted for specific products (see coverage criteria).
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