Specialty Drugs and Pharmacy Drugs

Here is where you’ll find all the information you need on our prescription drug coverage.

Drug Lists

• Some members need prior authorization for certain drugs.
• The Quantity Management program limits the amount of certain drugs a plan will cover.
• The Step Therapy program helps ensure quality, cost-effective drug therapy. 
• Excluded Drug List — This is a list of drugs that are excluded from coverage. The document also includes information on how to request a formulary exception for an excluded drug.
• $0 Covered Drug List — Under Health Care Reform, the Affordable Care Act (ACA) requires most health plans to cover certain drugs at $0 cost to members.

How Patients Can Save Money

• Use a Network Pharmacy — For your patients to have coverage under their benefit plan, they should use one of the 66,000+ pharmacies in our network.
• Lifestyle Medication Discount Program — If your patients have pharmacy benefits through BlueChoice HealthPlan, some non-covered medications may be available to them at a discount.

Helpful Resources

• Search for a Specific Drug — Use the drug cost tool to search for a specific drug. (This link leads to a third party website. That company is solely responsible for the contents and privacy policy on its site.) For personal information about their drug coverage, members can log into My Health Toolkit^®.
• My Health Toolkit — Members can compare drug costs, locate a pharmacy, review their prescription drug histories and much more.

BlueChoice HealthPlan provides coverage for specialty drugs under both the pharmacy and medical benefit. Members must fill oral and self-injectable medications through our preferred specialty pharmacy to have coverage under their pharmacy benefit. To get a patient set up, please call 877-259-9428.

To request prior authorization for specialty drugs billed under the pharmacy benefit, call 855-811-2218. 

Look at our complete Specialty Drug List to find out which drugs are covered and which require prior authorization under the pharmacy benefit. 

BlueCross^® BlueShield^® of South Carolina and BlueChoice HealthPlan require prior authorization for some specialty drugs billed under the medical benefit. Also, the medical benefit does not cover certain self-administered specialty drugs. 

Drug costs continue to rise, and specialty drugs are contributing significantly to that trend. BlueChoice^® has managed specialty drugs under the pharmacy benefit for several years, through prior authorization (PA), preferred drug strategies and, more recently, drug exclusions. We have also begun to manage specialty drugs under the medical benefit. Here are the current programs under the Specialty Medical Benefit Management (SMBM) strategy:

• Prior Authorization: Some medical (injectable or infusible) specialty drugs will require prior authorization. In addition, some infused specialty medications commonly administered in physician offices and hospitals will only be authorized to be provided in approved sites of care, such as at home or an infusion suite.
• Self-Administered Drugs: Certain self-administered drugs that were covered under the member’s medical benefit will only be covered under their pharmacy benefit. The pharmacy benefit will continue to cover these drugs. Hematologists, oncologists, nephrologists and rheumatologists may continue to bill these drugs under the medical benefit. 

Which drugs are included on the medical specialty drug lists?

Please see these lists:

• Medical Drug List
• Self-Administered Drug List

While these lists may change at any time, we expect to make changes quarterly.

Note: Prior authorizations for medical specialty drugs have always been a requirement for BlueChoice members. The attached is a comprehensive list that includes additional medical specialty drugs that require prior authorizations.

BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross Blue Shield Association.