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Pharmacy Optimization Initiative Highlights – 1st Quarter 2014

April 10, 2014

Our pharmacy program initiatives continue to help improve the services we make available to you and your patients. To help you keep up with the latest news, we’ll be posting a summary at the end of each quarter. Each quarterly update will spotlight recent enhancements, tools and programs, along with links to articles and resources you may have missed.

Here are some highlights from the 1st Quarter 2014:

January/February

Self-administered Specialty Drug Updates

In 2013, Blue Cross and Blue Shield of New Mexico (BCBSNM) expanded its claims processing system to automatically redirect professional electronic (837P) and paper (CMS-1500) claims to help ensure application of correct benefits for drugs approved by the U.S. Food and Drug Administration for self-administration. As of Jan. 1, 2014, the last “wave” of system edits was implemented for fertility, oral oncology, and various other select self-administered specialty drugs. Details were published in an article titled, Self-Administered Specialty Drug Claim Processing Reminder .

GuidedHealth® Program Updates

BCBSNM uses the GuidedHealth clinical rules platform to help monitor and promote appropriate use, safety and cost effectiveness of medications prescribed to our members. Patients with potential drug therapy issues may be identified based on claims data. Articles are published in the Blue Review to help keep you informed about areas of focus. For a listing of programs implemented in third quarter 2013, as well as an update on action you may need to take if you receive a letter, refer to the article titled GuidedHealth Helps Identify Drug Therapy Opportunities .

National Drug Code (NDC) Pricing Reminders & Resources

Many resources are available to assist you when billing with NDCs on medical claims, such as our NDC Billing Guidelines  and Frequently Asked Questions. There’s also an NDC Billing Tutorial and an NDC Units Calculator Tool available to contracted providers who are registered for our secure site, Blue Access for ProvidersSM . We’ve also published a number of reminder articles, based on feedback from providers. For example, while you may know that, when you bill for drugs on medical claims, the NDC must be valid for the date of service, otherwise correct reimbursement cannot be applied. The following article, published in January 2014 , includes quick tips on how to guard against inadvertent use of inactive and obsolete NDCs: Check Your Records for Outdated Drug Codes

March

Electronic Tools for Prescription Drug Benefit Prior Authorization (PA) Requests

BCBSNM continues to enhance the process for submitting PA requests. Refer to the March Blue Review  article titled, Electronic Options for Pharmacy Prior Authorization (PA) Requests  to learn more about how online tools such as iEXCHANGE® can replace the need to fax paper forms, resubmit requests or call to check status of your request. This article focuses on iEXCHANGE, which includes electronic PA forms for specific drugs that may be considered for coverage under the medical benefit. The article also offers reminders on CoverMyMeds® , a tool for PA requests for drugs that may be considered for coverage under the member’s pharmacy benefit.

For More Information

Visit the Pharmacy Program section for information on drug lists, prior authorization/step therapy, specialty pharmacy programs and more. Also continue to watch for updates in our monthly Blue Review.

The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are instructed to exercise their own medical judgment. Pharmacy benefits and limits are subject to the terms set forth in the member’s certificate of coverage which may vary from the limits set forth above. The listing of any particular drug or classification of drugs is not a guarantee of benefits. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.

GuidedHealth is a registered trademark of Prime Therapeutics LLC (Prime), a pharmacy benefit management company. BCBSNM contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSNM, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. BCBSNM makes no endorsement, representations or warranties regarding GuidedHealth. If you have any questions about this product or services, you should contact Prime Therapeutics LLC directly.

CoverMyMeds is a registered trademark of CoverMyMeds LLC, an independent third party vendor that is solely responsible its products and services.


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