CurrentBlue Cross Blue Shield - MainePolicy N/A

Requirement to Obtain Certain Drugs from CVS Specialty Pharmacy

Governs procurement of specified specialty medications for Anthem commercial PPO and EPO members (medical benefit) effective for services on/after December 1, 2020; affects providers previously notified and who administer these drugs in-office or outpatient hospital settings.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyRequirement to Obtain Certain Drugs from CVS Specialty Pharmacy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 1, 2020

Next Review Date

Key ActionProviders must work with CVS Specialty to procure listed specialty medications and bill zero charge for the medication while submitting for administration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12/1/2020effective date

Anthem PPO/EPOplans affected

877-254-0015CVS phone

866-336-8479CVS fax

Specialty Drug Procurement and Billing Criteria

Specialty drug procurement and billing criteria

Requirements for procurement, billing, and potential denials:

For dates of service on or after December 1, 2020, ordering providers for Anthem commercial PPO/EPO members must procure all drugs listed on the Anthem CVS Drug List through CVS Specialty unless exempted by Anthem.

CVS Specialty will fulfill and ship specialty drugs to the provider's office, hospital, or other designated location; providers impacted by this requirement have been previously notified separately and only applies to those specific providers.

Providers should continue to submit claims for administration of the medication but must bill a zero charge for the medication itself; CVS Specialty will bill Anthem directly for the medication and be paid by Anthem.

If certain specialty medications are obtained through other pharmacies, the claim will be denied.

Support and enrollment

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyRequirement to Obtain Certain Drugs from CVS Specialty Pharmacy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 1, 2020

Next Review Date

Key ActionProviders must work with CVS Specialty to procure listed specialty medications and bill zero charge for the medication while submitting for administration.

SourceLink

On This Page

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Provider Procurement & Billing Responsibilities

Billing Rule

Procure listed specialty drugs through CVS Specialty and bill medication at $0

For dates of service on or after December 1, 2020, ordering providers for Anthem commercial PPO/EPO members must work with CVS Specialty to procure all drugs listed on the Anthem CVS Drug List that are covered under the member's medical benefit. Providers should continue to submit claims for administration of the medication but must bill a zero charge for the medication itself; CVS Specialty will bill Anthem directly and be paid for the medication. CVS Specialty will ship drugs to the provider’s office, hospital, or location of choice. Contact CVS Specialty's Dedicated Anthem Team for assistance (phone/fax) or Anthem contract manager/Network Relations for participation terms.

Effective date: December 1, 2020
Providers must procure listed drugs through CVS Specialty unless exempted by Anthem
Submit claim for administration only and bill zero charge for the medication
CVS Specialty will bill Anthem directly and ship to provider location
CVS Specialty Dedicated Anthem Team: Phone 877-254-0015; Fax 866-336-8479

Denial Risk

Denial risk if specialty drugs are not procured through CVS Specialty

Claims for certain specialty medications that are obtained through pharmacies other than CVS Specialty will be denied.

This denial condition applies to drugs on the Anthem CVS Drug List unless Anthem has provided an exemption
Providers impacted were previously notified separately

Defined Terms

Designated provider (CVS Specialty Pharmacy)

TermCVS Specialty Pharmacy

DefinitionDesignated provider of certain specialty medications for Anthem (Anthem Medical Specialty Pharmacy initiative)

RoleProvides fulfillment and distribution of specified specialty drugs, ships medications to provider offices/hospitals, and bills Anthem directly for the medication.

Contact - Dedicated Team Phone877-254-0015

Contact - Dedicated Team Fax866-336-8479

Hours of OperationMon-Fri 5:00 am - 7:30 pm Pacific; Sat 6:00 am - 10:00 am Pacific

Affected providers

TermAffected providers

DefinitionProviders previously notified separately who administer listed specialty drugs in office or outpatient hospital settings

ScopeApplies to ordering providers for Anthem commercial PPO/EPO members for dates of service on or after December 1, 2020

Billing expectationContinue to submit for administration and bill a zero charge for the medication; CVS Specialty will bill Anthem directly for the drug.

Consequence of noncomplianceClaims for certain specialty medications obtained through other pharmacies will be denied.

OpenPayer

Requirement to Obtain Certain Drugs from CVS Specialty Pharmacy

Specialty Drug Procurement and Billing Criteria

Medication Billing Instruction

Provider Procurement & Billing Responsibilities

Defined Terms