CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Split Fill Program Drug List — Coverage Criteria

Drugs included in Blue Cross Blue Shield - Oklahoma's split fill program for members new to therapy; identifies medications subject to partial (split) fills to reduce waste and costs. Affects members and prescribers when a member has not filled the medication in the prior 120 days.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicySplit Fill Program Drug List — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify member benefits via the phone number on the patient's ID card prior to dispensing; members new to therapy may receive a prorated split fill for up to 3 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 monthsMax split fill duration

120 daysNew to therapy defined as

multipleOral oncology listed

includedOther specialty categories

Split Fill Program Coverage Criteria

Covered when ALL of the following are met

Split fill eligibility: Member is new to therapy (no prescription filled in prior 120 days) AND medication is listed on the Split Fill Program Drug Listup to 3 months partial fill allowed

Each drug has evaluated frequency and duration for split fill requirements

The inclusion of a drug on the Split Fill Program Drug List does not guarantee coverage or benefits for every member. Members and providers must refer to the member’s certificate or contract of coverage for complete details, including benefits, limitations, and exclusions. For final coverage determination, verify benefits using the phone number on the member’s ID card.

Provider Actions and Program Operation

Note

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicySplit Fill Program Drug List — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify member benefits via the phone number on the patient's ID card prior to dispensing; members new to therapy may receive a prorated split fill for up to 3 months.

SourceLink

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Eligibility for Split Fill

Members new to therapy (no prescription filled in the past 120 days) are eligible for a prorated partial ("split") fill. The partial fill is intended to cover up to 3 months of therapy and is applied when the drug is listed in the Split Fill Program. Drugs are evaluated for frequency and duration of split-fill requirements using evidence-based criteria; the program targets medications with high early discontinuation or dose-change rates.

Eligibility: Member has not filled the same medication in the past 120 days.
Split-fill duration: Partial fill prorated for up to 3 months of therapy (program-determined frequency/duration).

Prior Authorization

Benefit Verification

Verify member pharmacy benefits and coverage prior to dispensing by calling the phone number on the member's ID card or using the payer's electronic verification tools. Coverage for medications listed in the program depends on the member's certificate or contract; benefits, limitations, and exclusions in the member's plan determine final coverage. When in doubt, confirm with the plan or Prime Therapeutics (if applicable) to determine whether the split-fill program and the specific drug are covered for that member.

Use phone number on patient ID card for benefit verification.
Final coverage is determined by the member's certificate/contract.
Prime Therapeutics provides pharmacy solutions for BCBSOK and may be involved in benefit determination.

Denial Risk

Not Eligible for Split Fill

Members who have filled the medication within the past 120 days are not considered new to therapy and are therefore outside the definition for split-fill eligibility; do not provide prorated partial fills for these members under the split-fill program.

Not new to therapy = filled same medication within past 120 days.
Members meeting this condition are not eligible for split-fill prorated partial fills.

Initial Therapy - Split Fill

Members new to therapy

Initial split fill: Member has no prescription filled in past 120 days for the drug AND drug is on the Split Fill Program Drug Listpartial/prorated fill provided for up to 3 months

Drugs evaluated for frequency/duration of split fill requirements

Step Therapy / Drug-specific Split Fill Durations

Drug / Drug Class	Split Fill Frequency / Duration	Program Rationale
Oral oncology agents (see full drug list)	Prorated partial (split) fill provided for members new to therapy — up to 3 months; individual drug frequency/duration evaluated per drug	Targets drugs with high rates of early discontinuation or dose changes to minimize waste and reduce plan costs
Other specialty drugs (selected agents)	Prorated partial (split) fill provided for members new to therapy — up to 3 months; individual drug frequency/duration evaluated per drug	Program applies evidence-based evaluation to determine split fill requirements for drugs with early discontinuation potential

Key Definitions

New to therapy

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

Eligibility windowNo prescription fill for the medication in the prior 120 days defines 'new to therapy'.

ApplicationApplies to members initiating any medication listed on the Split Fill Program Drug List.

Split fill

DefinitionA partial dispensation of medication with a prorated member cost share amount for up to 3 months of therapy.

Duration limitProrated split fills are provided for up to 3 months of therapy.

PurposeIntended to minimize medication waste and reduce plan costs for drugs with high early discontinuation or dose-change rates.

Drug evaluationEach drug is evaluated to determine the frequency and duration of split fill requirements.

Background and Rationale

Split fill programs are designed to reduce medication waste and lower costs by dispensing a partial supply when there is a high likelihood of early therapy discontinuation or dose change. For this program, a split fill is a prorated partial dispensation of medication (with a prorated member cost share) provided for up to 3 months of therapy for members who are new to therapy (no fill in the prior 120 days). The document lists oral oncology and other specialty medications that have been designated for split fills; these lists are subject to change without notice.