Specialty Medical Medications
Specialty medications often are covered under the medical benefit. They can be costly for our members, and not all plans cover them the same way. That’s why it’s important to review whether the use of these medications meets coverage criteria before a specialty drug is provided.
The program also includes requirements for self-administered drugs and site-of-care that may impact coverage, which is important to know if you provide these types of medications.
Medical Specialty Drugs
To find out which medical specialty drugs require prior authorization under the Specialty Medical Benefit Management (SMBM) program, view the Medical Drug List.
Note: Some infused specialty medications commonly administered in the hospital setting can be safely provided at home, in a physician’s office, or in an infusion suite. Drugs with a site-of-care requirement may only be approved in certain sites of care or if the patient is under 18 years of age.
You can request prior authorization for these specialty drugs by using MBMNow through My Insurance ManagerSM (MIM).
- Log into MIM.
- Select the “Patient Care” tab.
- Under “Health,” look for “Pre-Certification/Referral.”
- When you indicate your request is for a specialty drug, the system will route you to MBMNow.
- Initiate your prior authorization request.
Certain self-administered drugs aren’t covered under the medical benefit. The drugs on the Self-Administered Drug List must be billed under the pharmacy benefit. There are some exceptions. Hematologists, oncologists, nephrologists and rheumatologists may continue to bill for these drugs under the medical benefit. Additionally, some member benefit plans may be exempt.
We make changes to all of our drug lists from time to time. Updates usually occur quarterly but can happen at any time. It’s always a good idea to review the latest version before providing a specialty drug to one of your patients who has coverage through BlueCross.
- Frequently Asked Questions
- Specialty Medical Drug Prior Authorization Presentation
- Specialty Medical Drug (Cancer) Prior Authorization Presentation
Access user guides for cancer and specialty authorizations in MBMNow’s Contact Us page. After going to MIM, choose a specialty drug authorization which will sign you into MBMNow.