Currentblue cross blue shield - michiganPolicy N/A

Pharmacy vs Medical Benefit Determination for Select Drugs and Vaccines

Lists specific drugs, diabetic testing supplies, CGMs, and vaccines and indicates whether they automatically pay under the medical benefit or may require a Part D versus Part B coverage review; applies to Blue Cross Blue Shield of Michigan members obtaining products from pharmacies.

Policy Summary

Payerblue cross blue shield - michigan

PolicyPharmacy vs Medical Benefit Determination for Select Drugs and Vaccines

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionShow the pharmacist your Blue Cross member ID card when obtaining products from a pharmacy provider.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9document chunks

Multipleproduct categories

COVID/Flu/Pneumovaccines auto-pay

HepBvaccines review

Coverage Criteria — Pharmacy vs Medical Benefit Determination

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.

Automatic medical benefit items

Products that will pay automatically under the medical benefit (no Part D vs Part B review required):

ALL of the following

Examples
- Topotecan (GEQ of Hycamtin®)
- Temozolomide (GEQ of Temodar®)
- Capecitabine (GEQ of Xeloda®)
- Etoposide
- Nebulizer solutions and inhalation products listed (e.g., acetylcysteine solution; albuterol solution; Bethkis® (tobramycin) inhalation solution; Brovana® (arformoterol tartrate); cromolyn solution; ipratropium solution; ipratropium/albuterol solution; Nebupent® (pentamidine isethionate) solution; Perforomist® (formoterol fumarate) solution; Pulmicort® (budesonide) solution; Pulmozyme® (dornase alfa) solution; Tobi® (tobramycin) solution; Xopenex® (levalbuterol hydrochloride) solution; Yupelri® (revefenacin) solution)

Diabetic supplies and CGMs

Diabetic testing supplies and Continuous Glucose Monitors listed (may be subject to Part D vs Part B review as noted):

ALL of the following

Meters & test strips
- Accu-Chek® Guide
- Accu-Chek® Guide Me
- Accu-Chek® Aviva Plus Test Strips
- Accu-Chek® Guide Test Strips
- Accu-Chek® Smart View Test Strips
- Contour® Next
- Contour® Nex EZ
- Contour® Nex GEN
- Contour® Next ONE
- Contour® Test Strips
- Contour® Next Test Strips
- Contour® Plus Test Strips
Continuous Glucose Monitors (CGMs)
- FreeStyle Libre Reader/Sensor/Continuous glucose monitoring system
- Dexcom G Series Reader/Sensor/Continuous glucose monitoring system

Provider Actions and Billing Notes

Documentation Required

Member Presentation Requirement

Members must present their Blue Cross member ID card to the pharmacist when obtaining covered items from a pharmacy under the medical benefit.

Show member ID card at pharmacy
Medical benefit may be used to obtain listed products from pharmacy providers

Billing Rule

Part D vs Part B Coverage Review

Some drugs and supplies may require a Part D versus Part B coverage review to determine the correct benefit. Certain listed items will pay automatically under the medical or pharmacy benefit based on the pharmacy claim submission and do not require a review.

Drugs that pay automatically under medical or pharmacy benefit (no Part D vs Part B review): Topotecan (GEQ of Hycamtin), Temozolomide (GEQ of Temodar), selected nebulizer solutions and brands (e.g., acetylcysteine solution; albuterol solution; Bethkis; Brovana; cromolyn solution; ipratropium solution; ipratropium/albuterol solution; Nebupent; Perforomist; Pulmicort; Pulmozyme; Tobi; Xopenex; Yupelri), Capecitabine (GEQ of Xeloda), Etoposide.
Items that may require Part D vs Part B coverage review: listed oral antiemetics, oral antineoplastics, oral immunosuppressants, and certain brand-name drugs and formulations; continuous glucose monitors and related systems (e.g., FreeStyle Libre, Dexcom G series) may also require review.
When review is required, the correct benefit (medical or pharmacy) will be determined by the Part D vs Part B coverage review process.

Definitions and Abbreviations

GEQ

DefinitionGEQ indicates generic equivalent.

Example - TopotecanListed as GEQ of Hycamtin® (Topotecan).

Example - TemozolomideListed as GEQ of Temodar® (Temozolomide).

Part D versus Part B coverage review

DefinitionPart D versus Part B coverage review: a determination process to identify whether a product is paid under the pharmacy (Part D) or medical (Part B) benefit.

When requiredCertain listed items (e.g., specified oral antiemetics, oral antineoplastics, oral immunosuppressants, select diabetic supplies/CGMs, and some vaccines) may require this review to determine correct benefit.

Member actionIf determined appropriate, these medications may be obtained from your pharmacy provider using the medical benefit.

Automatic medical examplesSome items do not require review and pay automatically under medical or pharmacy benefit based on claim submission (see list).

Hepatitis‑B vaccinesHepatitis‑B vaccines (Engerix‑B®, Recombivax HB®, PreHevbrio™) appear in the document and may be subject to review as noted elsewhere.