CurrentBlue Cross Blue Shield - AlabamaPolicy N/A

Prime Therapeutics Provider‑Administered Specialty Pharmacy Drug List

Lists provider‑administered specialty medications, their prior authorization (PA) status, in‑network specialty pharmacy requirements, limited distribution flags, and exceptions for PEEHIP members for Blue Cross and Blue Shield of Alabama members managed by Prime Therapeutics.

Policy Summary

PayerBlue Cross Blue Shield - Alabama

PolicyProvider‑Administered Specialty Pharmacy Drug List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for drugs marked (PA) and ensure in‑network specialty pharmacy billing for drugs denoted by the in‑network arrow when seeking in‑network benefits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+specialty drugs listed

Accredo, CVSin-network examples

ManyPA flagged

SomeLimited distribution

Lemtrada/Synagis/SpravatoPEEHIP exceptions

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Coverage rules and disclaimers

Coverage and access rules reflected on the list:

Drugs marked (PA) require prior authorization before coverage is allowed.

Drugs marked with an arrow must be obtained and billed by an in‑network medical specialty pharmacy for in‑network benefits.

Drugs marked with * are limited distribution; manufacturer or FDA distribution restrictions apply and may limit dispensing to select pharmacies.

For PEEHIP members, provider‑administered medications on this list are excluded from specialty pharmacy access and must be obtained via buy‑and‑bill, except: Lemtrada requires specialty pharmacy; Synagis and Spravato may be obtained via buy‑and‑bill or specialty pharmacy.

Inclusion on the Specialty Pharmacy Drug Management List or successful claim adjudication is not a guarantee of payment.

Coding and payment notes

Codes not listedmixed

No explicit CPT/HCPCS/NDC codes provided in this document.

Payment caveat — adjudication is not guarantee of payment

Payment caveatInclusion on the Specialty Pharmacy Drug Management List or successful adjudication of a pharmacy claim is not a guarantee of payment.

List subject to changeThis list is subject to change without notice.

Third-party administratorPrime Therapeutics LLC is an independent company contracted by Blue Cross and Blue Shield of Alabama to provide pharmacy benefit management services.

Specialty pharmacy independenceAccredo Health Group, Inc. and CVS/Caremark are independent specialty pharmacies serving eligible members.

Product ownershipProduct names are the property of their respective owners.

Authorization, specialty pharmacy, and PEEHIP exceptions

Prior Authorization

Prior Authorization Required

Many drugs on this specialty list require Prior Authorization (PA) before services or supplies will be covered. When a drug is annotated with (PA) the provider must obtain approval from the plan prior to administering or dispensing the medication to avoid claim denials or delays.

(PA) = Prior Authorization required — submit clinical documentation per plan requirements.
Drugs marked with an arrow () must be obtained and billed by an in‑network medical specialty pharmacy.
Limited distribution (*) drugs may only be available through a restricted set of pharmacies per the manufacturer or FDA.

Billing Rule

In‑network Specialty Pharmacy Billing Requirement

Some medications on this list must be obtained and billed by an in‑network specialty pharmacy to receive in‑network benefits. The in‑network specialty pharmacies include Accredo Health Group, Inc. and CVS/Caremark; always verify the member's benefit plan for the complete list of in‑network specialty pharmacies and any pharmacy-specific enrollment requirements.

Terms and key annotations

Specialty medications — definition and operational characteristics

DefinitionSpecialty medications are generally prescribed for people with complex or ongoing medical conditions and are high‑cost; they may be injected or infused, sometimes oral, and usually not stocked at retail pharmacies.

Operational characteristicsOften require unique storage or shipment requirements and additional education and support from a healthcare professional.

Distribution and stockingNot typically stocked at retail pharmacies; some specialty drugs are limited distribution (manufacturer or FDA restricts dispensing to select pharmacies).

Provider/benefit noteFor PEEHIP members, provider‑administered medications on this list are excluded from specialty pharmacy access and must be obtained through buy‑and‑bill, with specific exceptions (Lemtrada, Synagis, Spravato).

In‑network specialty pharmacy requirementTo receive in‑network benefits, the specialty pharmacy filing the claim must contract with the Blue Cross and Blue Shield Plan where the provider is located; example in‑network pharmacies include Accredo and CVS/Caremark.

Billing Rule

PEEHIP Member Exceptions and Buy‑and‑Bill Rule

FOR PEEHIP MEMBERS ONLY: Provider‑administered medications listed in this specialty drug policy are excluded from specialty pharmacy distribution and must be obtained through buy‑and‑bill, except for a few named exceptions. Follow PEEHIP guidance to ensure correct procurement and billing to avoid benefit or payment issues.

PEEHIP excludes provider‑administered medications from specialty pharmacy — these must be obtained via buy‑and‑bill.
Exceptions: Lemtrada requires use of a specialty pharmacy; Synagis and Spravato may be obtained either via buy‑and‑bill or specialty pharmacy.
Verify member is PEEHIP before applying the buy‑and‑bill rule; check plan documents for any additional exceptions or updated instructions.