self-administered injectable and oral biotechnology drugs · the current list of drugs (as of sept....

Volume 17 • Issue 10 • october 2015 Newsletter Excerpt In the past, many patients found they could not tolerate these drugs and, therefore, many dosages were not used. This program greatly reduces the amount of unused dosages of these medications, some of which can cost thousands of dollars per month. Please Note: • These drugs will NOT be covered if they are obtained at a retail pharmacy or via mail order service. • This program can be used by all Highmark members. However, due to Medicare Part D prescription drug coverage regulations, it is NOT mandatory for Medicare Advantage patients. Patients that are enrolled in Highmark Medicare Advantage plans may continue to obtain these drugs at a retail pharmacy or through mail order service. Medicare Advantage members can also elect to obtain their specialty drugs through Walgreens Specialty Pharmacy. As always, member benefits do vary. Providers should continue to verify all members’ benefits prior to service via the Eligibility and Benefits Inquiry function on NaviNet. Simplified Precertification Process There are no changes to medical policy or procedures connected with this program. Highmark members whose benefit designs currently require prior authorization for the drugs contained on the list will continue to require prior authorization. Providers are responsible for obtaining prior authorization for their patients. To initiate the precertification process and order these drugs for your patients, you need only make one call to WSP at 1-888-347-3416. This process saves you time and helps your patients receive their medications promptly and directly at their homes. Providers can also use the NaviNet Authorization Submission transaction for prescription drug authorizations. This transaction can be used for any pharmacy authorization requests, including non-formulary exception requests, prior authorizations or Managed Rx Coverage (MRxC) programs. The current list of drugs (as of Sept. 21, 2015) that are included in the program is included here for your convenience: Retail Exclusivity Drug List. You can also find this information under Pharmacy/Formulary on Highmark’s Provider Resource Center. Go to Pharmacy/Formulary Information, and then select Program for Self-Administered Injectable or Oral Biotechnology Drugs. If you have questions about this program or the drugs included on the current list of drugs, please call Provider Service at 1-866-262-5635. New Service Begins Jan. 1, 2016 Highmark continues to expand on the services provided to professional providers. In conjunction with our commitment to quality and cost containment, we are introducing a new program for Self-Administered Injectable and Oral Biotechnology Specialty Drugs. Beginning Jan. 1, 2016, your patients who are currently enrolled in Highmark health plans AND those who have transitioned from BCNEPA’s First Priority Health and First Priority Life Insurance Company health plans to Highmark health plans will need to obtain the specialty drugs they use exclusively from Walgreens Specialty Pharmacy (WSP). This program will also apply to new Highmark health plans as they are introduced. Program Benefits The Self-Administered Injectable and Oral Biotechnology Specialty Drug program is designed to: • Enhance integrated care and utilization management for patients who use these drugs • Ensure the drugs are administered in the most appropriate and effective manner • Simplify the precertification process for these medications • Reduce costs by minimizing waste Self-Administered Injectable and Oral Biotechnology Drugs

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Page 1: Self-Administered Injectable and Oral Biotechnology Drugs · The current list of drugs (as of Sept. 21, 2015) that are included in the program is included here for your convenience:

Volume 17 • Issue 10 • october 2015 Newsletter Excerpt

In the past, many patients found they could not tolerate these drugs and, therefore, many dosages were not used. This program greatly reduces the amount of unused dosages of these medications, some of which can cost thousands of dollars per month.

Please Note:• ThesedrugswillNOTbecoverediftheyareobtainedataretailpharmacyor viamailorderservice.

• ThisprogramcanbeusedbyallHighmarkmembers.However,duetoMedicarePartDprescriptiondrugcoverageregulations,itisNOTmandatoryforMedicareAdvantagepatients.PatientsthatareenrolledinHighmarkMedicareAdvantageplansmaycontinuetoobtainthesedrugsataretailpharmacyorthroughmailorderservice.MedicareAdvantagememberscanalsoelecttoobtaintheirspecialty drugs through Walgreens Specialty Pharmacy.

Asalways,memberbenefitsdovary.Providersshouldcontinuetoverifyallmembers’benefitspriortoserviceviatheEligibility and Benefits Inquiry functiononNaviNet.

Simplified Precertification ProcessThere are no changes to medical policy or procedures connected with this program.Highmarkmemberswhosebenefitdesignscurrentlyrequirepriorauthorizationforthedrugscontainedonthelistwillcontinuetorequirepriorauthorization.Providersareresponsibleforobtainingpriorauthorizationfor their patients.

To initiate the precertification process and order these drugs for your patients, youneedonlymakeonecalltoWSP at 1-888-347-3416.Thisprocesssavesyoutimeandhelpsyourpatientsreceivetheirmedicationspromptlyanddirectlyattheir homes.

ProviderscanalsousetheNaviNetAuthorization Submission transaction for prescriptiondrugauthorizations.Thistransactioncanbeusedforanypharmacyauthorizationrequests,includingnon-formularyexceptionrequests,priorauthorizationsorManagedRxCoverage(MRxC)programs.

Thecurrentlistofdrugs(asofSept.21,2015)thatareincludedintheprogram isincludedhereforyourconvenience:Retail Exclusivity Drug List. You can also find this information under Pharmacy/FormularyonHighmark’s Provider Resource Center. Go to Pharmacy/Formulary Information, and then select Program for Self-Administered Injectable or Oral Biotechnology Drugs.

Ifyouhavequestionsaboutthisprogramorthedrugsincludedonthecurrent list of drugs, please call Provider Service at 1-866-262-5635.

New Service Begins Jan. 1, 2016 Highmarkcontinuestoexpandontheservicesprovidedtoprofessionalproviders.Inconjunctionwithourcommitmenttoqualityandcostcontainment, we are introducing a newprogramforSelf-AdministeredInjectableandOralBiotechnologySpecialty Drugs.

BeginningJan.1,2016,yourpatientswhoarecurrentlyenrolledinHighmarkhealthplansANDthosewhohavetransitionedfromBCNEPA’sFirstPriorityHealthandFirstPriorityLifeInsuranceCompanyhealthplanstoHighmarkhealthplanswillneedtoobtainthespecialty drugs they use exclusively from Walgreens Specialty Pharmacy (WSP). This program will also apply to newHighmarkhealthplansasthey are introduced.

Program BenefitsTheSelf-AdministeredInjectableandOralBiotechnologySpecialtyDrugprogramisdesignedto:

• Enhanceintegratedcareandutilization management for patients who use these drugs

• Ensurethedrugsareadministered in the most appropriate and effectivemanner

• Simplifytheprecertificationprocessfor these medications

• Reducecostsbyminimizingwaste

Self-Administered Injectable and Oral Biotechnology Drugs

https://www.highmarkblueshield.com/health/pdfs/retail-exclusivity-list.pdf

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