CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Specialty Drugs coverage overview

Explains how specialty drugs are defined and how they are covered under pharmacy vs medical benefits for Blue Cross Blue Shield - South Carolina members, and describes prior authorization, formulary exception, specialty pharmacy and contact procedures. Intended for providers, pharmacists and members interacting with pharmacy and medical benefits.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicySpecialty Drugs coverage overview

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFollow the applicable prior authorization process: call 855-811-2218 for pharmacy benefit drugs or sign into the provider portal / call 877-440-0089 (or fax 612-367-0742) for medical benefit prior authorization requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Prior AuthorizationPA requirement

855-811-2218Pharmacy PA phone

877-440-0089Medical benefit PA phone

OptumPreferred specialty pharmacy

Specialty Drug Coverage Rules

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Coverage determination for specialty drugs

Coverage and benefit assignment depends on drug, route of administration, site of care and member's plan:

ANY of the following

Specialty drugs filled at the pharmacy are covered under the member's pharmacy benefit when the member's plan allows.
Specialty drugs administered in a medical setting by a healthcare professional are typically covered under the medical benefit.
Some self-administered specialty drugs must be filled under the pharmacy benefit and are not covered under the medical benefit.

Prior Authorization requirement

Drugs that require prior authorization:

ALL of the following

Prior Authorization is required when the plan determines a specialty drug requires PA before coverage will be provided.
PA decisions are based on FDA and manufacturer guidelines, medical literature, safety, accepted medical practice, appropriate use and benefit design.
A prior authorization approval does not guarantee eligibility or payment of a claim.
Some medical-benefit drugs may be authorized only for specific sites of care (e.g., infusion center or patient's home).

Formulary exceptions

When a specialty drug is excluded from coverage:

ALL of the following

Members or their prescribers may request a formulary exception if the prescriber believes no alternative will work for the member's condition.
Formulary exceptions require required documentation from the member's health care provider.

What Providers Must Do

Prior Authorization

Pharmacy prior authorization request

Call 855-811-2218 to request prior authorization for drugs covered under the pharmacy benefit.

Phone: 855-811-2218

Prior Authorization

Medical prior authorization request

Providers must sign into the health plan's provider website to access the online medical prior authorization system, or call 877-440-0089 or fax requests to 612-367-0742. Provider specialty is considered in reviews.

Phone: 877-440-0089
Fax: 612-367-0742
Note: Provider specialty is considered when reviewing medical and self‑administered drug PA requests.

Documentation Required

Formulary exception documentation

When requesting a formulary exception, submit required clinical documentation from the member's health care provider to support that no alternative drug will work.

Note

Specialty pharmacy routing

Under most plans, specialty drug prescriptions must be filled by the preferred specialty pharmacy (Optum Specialty Pharmacy). The specialty pharmacy will inform prescribers how to request PA when necessary.

Optum Specialty Pharmacy: 877-259-9428

Coding & Billing Notes

This policy document does not list any specific billing or procedure code groups. No CPT, HCPCS, NDC or other code sets are provided within the policy. For questions about claim coding or to confirm whether a particular medication or administration should be billed to the pharmacy or medical benefit, contact Blue Cross Blue Shield - South Carolina or refer to the member's specific plan documents and billing instructions; the preferred specialty pharmacy and health plan prior authorization contact numbers in the policy can assist with routing and authorization.

Clinical and Administrative Background

Specialty drugs are prescription medications used to treat complex or chronic conditions that typically require patient-specific dosing, careful clinical monitoring and may require special handling such as refrigeration. Coverage and benefit assignment depends on multiple factors, including the drug itself, the route of administration, the site of care and the member's plan.

When a specialty drug is dispensed at a pharmacy and the member's benefit permits, it is covered under the member's pharmacy benefit. Specialty drugs administered by a health care professional in a medical setting are typically covered under the medical benefit. Some specialty products that can be self‑administered nevertheless must be filled under the pharmacy benefit and are not covered under the medical benefit.

Prior Authorization (PA) may be required for specialty drugs as determined by the plan. PA decisions are based on FDA and manufacturer guidelines, medical literature, safety, accepted medical practice, appropriate use and benefit design. A PA approval does not guarantee eligibility or payment of a claim.

Defined Terms

Definitions

Specialty DrugsPrescription medications used to treat complex or chronic medical conditions that usually require patient-specific dosing, careful clinical monitoring and may require special handling.

Prior Authorization (PA)A program requiring approval from the health plan before certain medications will be covered, based on clinical guidelines, safety and benefit design.

Formulary ExceptionA request by a member or prescriber to cover a drug not on the plan formulary, requiring clinical documentation to justify use when alternatives are not suitable.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicySpecialty Drugs coverage overview

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

OpenPayer

Specialty Drugs coverage overview

Specialty Drug Coverage Rules

What Providers Must Do

Coding & Billing Notes

Clinical and Administrative Background

Defined Terms

Key Contact Numbers & Quick Facts

Specialty Drugs coverage overview

Specialty Drug Coverage Rules

What Providers Must Do

Coding & Billing Notes

Clinical and Administrative Background

Defined Terms

Key Contact Numbers & Quick Facts

Other Policies to Review