CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Split Fill Program Drug List — Split Fill Program Coverage Criteria

Lists drugs subject to the payer's split fill program that provides partial (prorated) initial fills for members new to therapy to reduce waste and cost; applies to members whose benefits include the program and to providers submitting prescriptions to Blue Cross Blue Shield - New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicySplit Fill Program Drug List — Split Fill Program Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes / informational

Effective DateN/A

Next Review DateN/A

Key ActionVerify member benefits using the number on the member's ID card before dispensing; full initial fills may be denied if the member is new to therapy and a split fill is required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipledrugs listed for split fill program

3 monthsmax split fill duration

120 daysnew-to-therapy look-back

Split Fill Program Coverage Criteria

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Eligibility: Member is new to therapy (no prescription for the medication filled in the past 120 days)120 days

From program definition; members new to therapy receive split fills

Medication listed: Medication is included on the payer's split fill program drug listlisted drug

See oral oncology and other category lists in the program drug list

Benefit coverage: Member's specific benefits include coverage for the listed drug class or split fill programbenefit inclusion

Providers must verify member benefits using the number on the member's ID card

Key Program Parameters

inv-03: New-to-therapy look-back — no prescription filled in the past 120 days

Look-back periodNo prescription filled in the past 120 days

PurposeDefines member as 'new to therapy' for split-fill eligibility

ApplicationApplies to members prescribed drugs on the split fill program list

inv-04: Maximum split fill duration — up to three months

Maximum durationUp to three months

Cost sharingPartial (prorated) member cost share for split fills

DeterminationEach drug's frequency and duration are set by evidence-based evaluation

Provider Responsibilities and Impact

Note

Prior Authorization / Coverage Verification

Prior authorization not specified in this document. Verify prior authorization requirements and any other utilization management rules through the member's ID card or the payer's provider systems before prescribing or dispensing.

Call the number on the member's ID card to confirm prior authorization and coverage details.

Billing Rule

Split Fill Requirement for New-to-Therapy Members

Members new to therapy (no fill in the prior 120 days) for drugs on the Split Fill Program will receive a partial (prorated) initial fill for up to three months. Each drug's initial fill may be prorated to reduce waste and member cost share. Providers and pharmacies should expect split (partial) fills for affected medications and coordinate dispensing accordingly.

Split fills apply for up to three months for members with no fill in the prior 120 days.
Each drug is evaluated to determine the frequency and duration of the split fill requirement.

Denial Risk

Potential Denial or Adjustment for Full Initial Fills

Claims for full initial fills for drugs on the Split Fill Program may be denied, adjusted, or reduced if the member is new to therapy and the program requires a partial (split) initial fill. Providers should prepare to dispense and bill partial fills when applicable to avoid claim denials or retrospective adjustments.

Full initial fill claims for listed drugs may be denied or adjusted for members new to therapy (no fill in prior 120 days).
Verify member status and follow split fill dispensing and billing procedures to reduce risk of denial.

Note

Verify Member Coverage

Verify member coverage before prescribing or dispensing. Listing of a drug in the Split Fill Program does not guarantee coverage for a specific member; benefits vary by contract. For questions about member benefits, call the number on the member's ID card.

A drug's presence on the program list is not a guarantee of coverage.
Contact the number on the member's ID card for coverage confirmation and benefit details.

Key Definitions

inv-10: New to therapy — A member without a prescription for the medication filled in the past 120 days.

DefinitionA member without a prescription for the medication filled in the past 120 days.

Role in eligibilityUsed to identify members eligible for initial split (partial) fills

VerificationProviders should verify member benefits as listing does not guarantee coverage

inv-11: Split fill — A partial, prorated medication fill provided to new-to-therapy members for an initial period (up to three months) to reduce waste.

DefinitionA partial, prorated medication fill provided to new-to-therapy members for an initial period (up to three months)

ObjectiveReduce medication waste and plan costs for drugs with high early discontinuation or dose changes

ImplementationMember pays prorated cost share; each drug's split-fill specifics are evidence-based

Initial Therapy Split Fill

Initial split fill policy for new-to-therapy members

Initial split fill: Provide a partial (split) fill of the medication at a prorated member cost share for members new to therapyup to three months

Split fills apply for up to three months; each drug's frequency and duration are determined by evidence-based evaluation