Self-administered Drugs: Requirement Reminders
For those medications that are self-administered, Blue Cross and Blue Shield of New Mexico (BCBSNM) members are required to use their pharmacy benefit and acquire the medication through a pharmacy provider. Self-administered drugs can include oral, patch and injectable products.
For your patients to receive benefit coverage, the covered self-administered drugs must be provided under their pharmacy benefit and not dispensed through the physician’s office.
In October 2012, BCBSNM is planning to implement a system edit that will deny services submitted on professional claims for self-administered drugs that are covered under the member’s prescription drug benefit. Denied service lines on the claim will receive the following message: "Self-administered drugs submitted by a medical professional provider are not within the member's medical benefits. These charges must be billed and submitted by a pharmacy provider. "
As a reminder, Prime Therapeutics Specialty Pharmacy (Prime Specialty Pharmacy) is the preferred specialty pharmacy for most BCBSNM members. To obtain specialty medications through the Prime Specialty Pharmacy:
- Collect Patient and Insurance Information
Use the Specialty Pharmacy fax form or your own prescription form, along with your office’s fax cover sheet. Be sure to include the physician’s signature and any clinical data that may support the approval process.
- Fax Signed Forms to 866-203-6010
Prime Specialty Pharmacy's team of pharmacists and benefit specialists will handle the details, from checking eligibility to coordinating delivery.
To help you determine the correct path for medication fulfillment and ensure that the correct benefit is applied, please refer to the Specialty Pharmacy Drug List . This list identifies those drugs that are approved for self-administration and covered under the patient’s pharmacy benefit.
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.