Currentblue cross blue shield - kansasPolicy N/A

Outpatient Medical Drug Exclusion List

Specifies prescription drugs and devices that are excluded from outpatient medical benefit coverage and must be obtained through the Prescription Drug Program (specialty/in‑network pharmacy); applies to affected Blue Cross Blue Shield - Kansas prescription drug plans and outpatient settings.

Policy Summary

Payerblue cross blue shield - kansas

PolicyOutpatient Medical Drug Exclusion List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain listed drugs and devices through the Prescription Drug Program (specialty or in‑network pharmacy); outpatient medical benefit does not cover them except for hospital emergency room medical emergencies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Several dozenlisted drugs/devices required to be purchased through pharmacy benefit

ResultsRxformulary

Emergency onlymedical benefit exception

ResultsRx, BlueRx, BlueCareprescription drug plans affected

Outpatient Medical Drug Exclusion and Exceptions

Covered when ALL of the following are met:

Drugs and devices listed are excluded from the outpatient medical benefit and must be purchased through a specialty or in‑network pharmacy, subject to member benefits (out‑of‑network purchases subject to out‑of‑network benefits).

If a brand name is listed, any available generics, authorized generics or biosimilars of that brand also apply.

Exception (medical emergency): Coverage under the medical benefit is allowed only when the drug is provided during a medical emergency in a hospital emergency room.

Applies to all ResultsRx prescription drug plans; applies to BlueRx Card and BlueCare prescription drug plans unless the group has opted out.

Policy Summary

Payerblue cross blue shield - kansas

PolicyOutpatient Medical Drug Exclusion List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Procurement and Billing Actions

Billing Rule

Procure via Prescription Drug Program

Procure via Prescription Drug Program: Certain drugs and devices are covered only when purchased through the Prescription Drug Program and must be procured via a specialty or in‑network pharmacy. If the member has out‑of‑network pharmacy benefits, purchases from other pharmacies will be processed under those out‑of‑network benefits. If a brand name is listed, available generics, authorized generics, or biosimilars of that brand also fall under this requirement.

Applies to drugs/devices listed on the Outpatient Medical Drug Exclusion List
If covered under ResultsRx formulary, the same restriction applies

Denial Risk

Outpatient medical benefit exclusion

Outpatient medical benefit exclusion: Benefits for the listed prescription drugs and devices are not covered under the outpatient medical benefit and are only covered through the Prescription Drug Program. Examples of outpatient settings include home health care agencies, physician offices, outpatient hospitals, or other outpatient facilities. These drugs may be covered under the medical benefit only when provided during a medical emergency in a hospital emergency room.

Covered only if purchased through a specialty or in‑network pharmacy; otherwise processed under pharmacy (including out‑of‑network) benefits
Coverage under medical benefit permitted only for hospital emergency room medical emergencies

Definitions and Formulary Applicability

inv-05: Outpatient setting (examples)

Home health careCare provided in a member's home by a home health care agency is considered an outpatient setting.

Physician officeServices delivered in a physician's office are an example of an outpatient setting.

Outpatient hospitalServices provided in an outpatient hospital setting are considered outpatient.

Other outpatient facilityAny other outpatient facility is included in the outpatient setting examples.

inv-06: Formulary applicability

Formulary to which list appliesAll drugs on the list apply to the ResultsRx formulary.

Brand/generic applicabilityIf a brand name is listed, any available generics, authorized generics or biosimilars of that brand also apply to ResultsRx.

Plan applicability noteApplies to members covered under ResultsRx prescription drug plans (see policy for applicability to other plans).

OpenPayer

Outpatient Medical Drug Exclusion List

Outpatient Medical Drug Exclusion and Exceptions

Coding and Medical Benefit Allowance

Provider Procurement and Billing Actions

Definitions and Formulary Applicability