CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Specialty Drug Management List (pharmacy specialty medications)

Defines the list of medications identified as specialty drugs for Blue Cross and Blue Shield of Oklahoma, how they are covered under pharmacy vs medical benefits, and guidance on approvals and specialty pharmacy use for members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicySpecialty Drug Management List (pharmacy specialty medications)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders should obtain prior authorization and request forms at bcbsok.com/provider or call the number on the member ID card.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiple pagesspecialty drugs listed (partial)

Pharmacy vs MedicalPharmacy vs Medical

Prime Therapeuticsthird-party vendor

Subject to changelist update notice

855-710-6984language assistance

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Coverage & Access for Specialty Drugs

Coverage summary

Coverage and access notes for specialty medications under BCBSOK plans.

The Specialty Drug Management List identifies medications the plans consider specialty medications; listing does not guarantee coverage and the list is subject to change.

Specialty medications that are FDA‑approved for self‑administration are often covered under the pharmacy benefit; those approved for administration by a health care professional are often covered under the medical benefit.

Some medications may be covered under either the pharmacy or medical benefit and may appear in both sections of the list.

Members or providers with questions should call the number on the member ID card.

Prior approval may be required before these drugs can be considered for coverage; request forms are available at bcbsok.com/provider and providers may call the number on the member ID card for benefit questions.

Specialty drug listing (informational)

Items listed are specialty drugs with categories and routes; no explicit coverage criteria provided in these chunks.

The document lists specialty drug entries showing drug name, Drug Category and Route of Administration (examples include GOCOVRI: Drug Category = PARKINSON, Route = OR; HUMIRA: Drug Category = AUTOIMMUNE, Route = SC).

A Route of Administration key is provided to interpret abbreviations (CO, EX, IJ, IM, IN, IO, IT, IV, IX, IZ, OP, OR, SC).

The list is informational; presence on the list does not, by itself, specify coverage criteria or guarantee coverage.

Medical Benefit Drug List and Provider Requirements

Drugs covered under the medical benefit and provider guidance:

Certain listed drugs are identified under 'Drugs Covered Under Your Medical Benefit' and include administration routes such as IV, IS, IJ and SC (examples in the list: ABECMA = IV; ACTEMRA = IV; AMVUTTRA = SC).

Your plan benefits may require prior authorization or other requirements before a medical‑benefit drug can be considered for coverage; providers can find request forms at bcbsil.com/provider and may call the number on the member ID card with questions.

To maximize benefits, confirm whether the pharmacy or provider is in‑network; call the number on the ID card for assistance locating in‑network providers or specialty pharmacies.

This medical‑benefit list includes the same Route of Administration key and is subject to change without notice.

Language assistance availability

Availability statement

Free language assistance and appropriate auxiliary aids and services are available in multiple languages for members and providers.

To access these services, call 855-710-6984 (TTY: 711) or speak with your provider.

Drug Listings, Routes & Coding

Route of administration metadatamixed

Drug entries include a Route of Administration key indicating OR, SC, IV, IJ, IM, IN, etc.

Drug entries (name, category, route)mixed

GOCOVRI

Drug Category = PARKINSON; Route of Administration = OR

Specialty drug roster (brand names with categories and routes)mixed

RINVOQ	Drug Category = AUTOIMMUNE; Route of Administration = OR
ABECMA	Drug Category = CANCER; Route of Administration = IV
AVASTIN	Drug Category = CANCER; Route of Administration = IV

Example route codes presentmixed

IV	Intravenous
SC	Subcutaneous

Route of administration codes (key)mixed

IV	Intravenous
SC	Subcutaneous
IM	Intramuscular
IT	Intrathecal
IZ	Intravitreal
IJ	Injection
OR	Oral
IX	Intraarticular
EX	External
IS	Intraspinal/Instillation (as used in list)

Prior Authorization & Provider Guidance

Prior Authorization

Prior Authorization Required

Please note: You may need approval before these drugs can be considered for coverage. Your doctor can find request forms at bcbsok.com/provider. Your doctor can also call the number on your ID card with any questions about your benefits. Based on the terms of your benefit plan, you may need to fill these prescriptions at an in-network specialty pharmacy to get the most out of your benefits. Call the number on your member ID card to help locate an in-network specialty pharmacy near you. BCBSOK members who use oral oncology or hemophilia specialty drugs may have other in-network specialty pharmacy options.

Provider forms and prior authorization information available at bcbsok.com/provider
Call the number on the member ID card for benefit or network specialty pharmacy questions

Note

Vendor Relationship & Notice

This list is subject to change without notice. Product names are the property of their respective owners.

Route of Administration key: CO=Combination, EX=External, IJ=Injection, IM=Intramuscular, IN=Inhalation, IO=Intraocular, IT=Intrathecal, IV=Intravenous, IX=Intraarticular, IZ=Intravitreal, OP=Ophthalmic, OR=Oral, SC=Subcutaneous
List may be updated at any time; verify current requirements before ordering or dispensing

Prior Authorization

Prior Authorization Notice & Provider Resources

Please note: Your plan benefits may have a prior authorization and/or added requirements that may need to be met before a drug can be considered for coverage. Your doctor can find request forms at bcbsok.com/provider. Your doctor can also call the number on your ID card with any questions about your benefits. To get the most out of your benefits, you should check if the pharmacy or provider used is in-network. You can call the number on your ID card for help.

Prior authorization and other coverage requirements may apply to medical-benefit drugs
Provider forms and additional resources at bcbsok.com/provider

Note

Contractor Relationship / Pharmacy Solutions

The relationship between Blue Cross and Blue Shield of Oklahoma and the specialty pharmacies is that of independent contractors. Prime Therapeutics LLC is a separate company contracted by Blue Cross and Blue Shield of Oklahoma to provide pharmacy solutions. Blue Cross and Blue Shield of Oklahoma, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.

Prime Therapeutics provides pharmacy solutions under contract with BCBSOK
Specialty pharmacies operate as independent contractors

Note

Specialty Drug List & Contractor Relationship

BCBSOK Specialty Drug Management List — This list is subject to change. Product names are the property of their respective owners. The relationship between Blue Cross and Blue Shield of Oklahoma and the specialty pharmacies is that of independent contractors. Prime Therapeutics LLC is a separate company contracted by Blue Cross and Blue Shield of Oklahoma to provide pharmacy solutions. Blue Cross and Blue Shield of Oklahoma, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.

Specialty drug list may change without notice — verify before prescribing or dispensing
Prime Therapeutics contractual relationship noted above

Definitions & Abbreviations

Specialty medications — definition and handling characteristics

DefinitionSpecialty medications are often prescribed to treat complex and/or chronic conditions (e.g., multiple sclerosis, hepatitis C, rheumatoid arthritis).

Handling/StorageMay have special handling and/or storage needs.

Benefit assignmentFDA‑approved self‑administered specialty medications are often covered under the pharmacy benefit; those approved for administration by a health care professional are often covered under the medical benefit.

Dual listingSome medications may appear under both pharmacy and medical sections when coverage could be under either benefit.

List scopeThe Specialty Drug Management List is not all‑inclusive and is subject to change; listing does not guarantee coverage.

Route of Administration key — abbreviations (set 1)

COCombination

EXExternal

IJInjection

IMIntramuscular

INInhalation

IOIntraocular

Route of Administration key — abbreviations (set 2)

ITIntrathecal

IVIntravenous

IXIntraarticular

IZIntravitreal

OPOphthalmic

OROral

Route of Administration key — abbreviations (set 3)

SCSubcutaneous

COCombination

EXExternal

IJInjection

IMIntramuscular

Prime Therapeutics relationship — contractor disclosure

Contractor statusPrime Therapeutics LLC is a separate company contracted by Blue Cross and Blue Shield of Oklahoma to provide pharmacy solutions.

Ownership interestBlue Cross and Blue Shield of Oklahoma, and several independent Blue Cross and Blue Shield Plans, have an ownership interest in Prime Therapeutics.

Specialty pharmaciesThe relationship between BCBSOK and specialty pharmacies is that of independent contractors.

Route of Administration key — additional examples

IVIntravenous

SCSubcutaneous

IJInjection

IMIntramuscular

OROral

Contractor disclosure — Prime Therapeutics LLC

Contractor rolePrime Therapeutics LLC provides pharmacy solutions to BCBSOK under contract.

Independent contractorsThe relationship with specialty pharmacies is described as independent contractors.

Corporate affiliationBCBSOK is a Division of Health Care Service Corporation and notes ownership interest in Prime Therapeutics along with other Blue plans.

Route of Administration — additional route key entries

IXIntraarticular

ISIntrasubstance/instillation (as used in list)

IZIntravitreal

OPOphthalmic

ITIntrathecal

Prime Therapeutics relationship — contractor relationship note

Contracted servicesPrime Therapeutics LLC is contracted by BCBSOK to provide pharmacy solutions; the list is subject to change without notice.

DisclaimerProduct names are the property of their respective owners.

Organizational noteBCBSOK is an Independent Licensee of the Blue Cross and Blue Shield Association and a division of Health Care Service Corporation.

Language assistance — free services and auxiliary aids/services

Assistance availabilityFree language assistance and appropriate auxiliary aids/services are available in multiple languages.

Contact numberCall 855-710-6984 (TTY: 711) for language assistance or auxiliary aids/services.

Provider optionMembers may also speak with their provider for assistance.