Pharmacy Program Highlights – 2nd Quarter 2015

Jul. 21, 2015

Blue Cross and Blue Shield of Montana (BCBSMT) continues to enhance the pharmacy program services and support we make available to you and your patients. This brief 2nd quarter summary highlights recent BCBSMT pharmacy initiatives and provides helpful reminders with links to related resources.


GuidedHealth® Program Updates

BCBSMT uses the GuidedHealth clinical rules platform to help monitor and promote appropriate use, safety and cost effectiveness of medications prescribed to our members. Informational letters are sent to providers regarding patients who may have potential drug therapy issues, as identified based on BCBSMT claims data. For some programs, the member may also receive a letter.

In the second quarter 2015, letters were sent regarding potential underutilization (non-adherence or non- prescribed drug regimen based on the identified member's condition) in the following areas:

  • Inhaled corticosteroids use in asthma
  • Adherence programs (cholesterol, diabetes, depression, hypertension and respiratory)

Reminder: Hepatitis C Pharmacy Prior Authorization Criteria Change Effective July 1, 2015

The BCBSMT Pharmacy Prior Authorization criteria for the Hepatitis C Second Generation and Sovaldi programs were updated to require a METAVIR score (or equivalent APRI, Ishak, Fibroscan score) of 2 or greater.* Patients who were on a therapy regimen prior to July 1, 2015, are not affected by this change.

The updated program criteria summaries are posted on the Prime Therapeutics website, which can be found in the Pharmacy Prior Authorization/Step Therapy section of our website.

*These changes apply to members with BCBSMT pharmacy benefits and the Hepatitis C prior authorization program as part of their existing pharmacy benefits. These changes do not apply to Medicare Part D customers.





CoverMyMeds is an online tool available to BCBSMT contracted providers for electronic completion and submission of prior authorization (PA) requests for prescription drugs that are part of the BCBSMT pharmacy PA program. Visit our CoverMyMeds page to get started and learn more.

Billing with National Drug Codes (NDCs)

When you bill with NDCs on medical claims submitted to BCBSMT, in addition to including the appropriate HCPCS or Current Procedural Terminology (CPT®) information, it helps facilitate more accurate payment and better management of drug costs based on what was administered and billed.

Select Medication List

NDC pricing has paved the way for other initiatives, such as our Select Medication List, which is being developed in stages to include specific drugs within particular classes or categories, based on safety and cost effectiveness. Currently, the list includes two medications from the viscosupplementation class that are used primarily for osteoarthritis knee pain relief. Choosing a drug from the Select Medication List and billing for it with the appropriate NDC will result in a higher reimbursement rate than the rate applied for other non- listed drugs in the same class. View the current BCBSMT Select Medication List PDF Document for details.

General Information

Visit the Pharmacy Program section for information on drug formularies, dispensing limits, prior authorization/step therapy, specialty pharmacy and more. Also continue to watch our News and Updates and quarterly Capsule News newsletter for details.

GuidedHealth is a registered trademark of Prime Therapeutics LLC (Prime), a pharmacy benefit management company. BCBSMT contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSMT, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. BCBSMT makes no endorsement, representations or warranties regarding GuidedHealth. If you have any questions about this product or services, you should contact Prime Therapeutics LLC directly.

CoverMyMeds is a registered trademark of CoverMyMeds LLC, an independent third party vendor that is solely responsible its products and services.

CPT copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

Please note that the fact that a service has been preauthorized/pre-certified is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member's certificate of coverage applicable on the date services were rendered. 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.

The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Physicians are instructed to exercise their own medical judgment. 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. Not all programs may be available to HMO members. 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.

View 2015 news and updates