Self-Administered Block Medication Update

Oct. 7, 2021

Beginning Jan. 1, 2022, the following specialty medications will no longer be covered or processed under the medical benefit for BlueCross BlueShield of South Carolina members who are subject to the Self-Administered Drug Block (SAB) component of the Specialty Medical Benefit Management (SMBM) program.

Additionally, those drugs noted with an asterisk (*) have an intravenous (IV) version in addition to the self-injectable version.  The IV version will, in addition to the self-administered version, be blocked under the medical benefit.  The member will need to fill the self-administered version under the pharmacy benefit.

Drug Name

J-Code

Afstyla

J7210

  Actemra*   J3262, J3490, J3590, C9399

Bynfezia Pen

J3490, J3590, C9399

Chorionic Gonadotropin

J0725

  Cimzia*   J0717

Coagadex

J7175

Corifact

J7180

Dupixent

J3490, J3590, C9399

Esperoct

J7204

Fasenra*

J0517

Forteo

J3110

Hemlibra

J7170

Idelvion

J7202

Ilumya

J3245

Intron A

J9214

Kevzara (sarilumab)

J3490, J3590, C9399

Kynamro

J3490, J3590, C9399

Natpara

J3490, J3590, C9399

Novarel

J0725

Nucala*

J2182

Obizur

J7188

Octreotide

J2354

  Orencia*   J0129

Otrexup

J3490, J3590, C9399

Ovidrel

J0725

Pregnyl

J0725

Rasuvo

J3490, J3590, C9399

Rebinyn

J7203

Relistor Injection

J2212

Riastap

J7178

Sandostatin

J2354

Sevenfact

J7212

Siliq

J3490, J3590, C9399

  Simponi/Simponi Aria*   J1602, J3490, J3590, C9399

Strensiq

J3490

Takhzyro

J0593

Taltz

J3490, J3590, C9399

Tegsedi

C9399, J3490

Teriparatide

J3110

Tremfya

J1628

Tretten

J7181

Tymlos

J3490, J3590, C9399

Tyvaso

J7686

Ventavis

Q4074

Vonvendi

J7179

Vyleesi

J3490, J3590

Xembify

J1558

  Xolair*   J2357

 

Please note the following:

  • These drugs are being added to the current SAB drug list of the SMBM program.  This is not a new program or initiative.
  • Any member with a current or active prior authorization approval will be allowed to continue receiving their drug under their medical benefit until the expiration date of the authorization.
  • When time for each member to renew their prior authorization, post Jan. 1, 2022, they will be required to move their therapy to the self-administered version of their drug.  The self-administered versions are covered under their pharmacy benefit.
  • Members can fill the self-administered versions of their drug at Optum Specialty Pharmacy, our preferred specialty pharmacy.
  • Pharmacy Management has notified impacted members by letter of the upcoming SAB benefit change for these targeted drugs.
  • Members and providers have the ability to submit medical necessity documentation to seek approval for members to remain on their current IV therapy or continue to receive the self-injectable version under their medical benefit when appropriate via the standard appeals process.
About the SAB Program

Our SAB program is similar to those offered by many other payor/health plans that steer medications that have both an IV and self-administered version from coverage under the medical benefit to the pharmacy benefit.

Our line of business clients have requested we be more proactive in shifting share away from more costly medical administered drugs to the self-administered versions via the pharmacy benefit to help reduce their company drug cost exposure.

Members may experience a cost-share under the pharmacy benefit when moving to the self-administered version.

Providers and members do have a process, via appeals, to submit medical necessity rationale for allowing members to stay on their IV therapy under medical, when necessary.

If you have any questions, please contact Provider Education using the Provider Education Contact Form located on www.SouthCarolinaBlues.com or www.BlueChoiceSC.com.

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