Medication policy user guide

This is a brief user guide about our medication policy, providing explanations of terms used and contact information should you have questions or need more information. 

Medication policy applies to the following types of medications:

1. Office-administered injectables
   HMO members – prior authorization through IPA or HMO Medical Operations
   PPO members – prior authorization through PPO Medical Operation
    
2. Home health/infusion injectables
   HMO members – prior authorization through delegated IPA or HMO Medical Operations
   PPO members – prior authorization through PPO Medical Operations
    
3. Home self-administered injectables
   HMO members – prior authorization through Blue Shield of California (BSC) Pharmacy Services
   PPO members – prior authorization through BSC Pharmacy Services
   PPO members without an outpatient prescription drug benefit – prior authorization through PPO Medical Operations

Explanation of fields

Below is a brief description of selected fields found within each medication policy. 

• Special instructions and pertinent information
  This section contains benefit information (e.g., Medical or Pharmacy coverage) and Blue Shield phone and fax numbers for where to call or send forms (e.g., Medical Operations, Pharmacy Services or Claims) This section may also contain information about specialty pharmacy distributors when applicable.
   
• Prior authorization/medical review is required for the following condition(s)
  This section describes the indications that require prior authorization medical review and the corresponding coverage requirements for those indications. Coverage determination is made prior to drug administration.
   
• The following condition(s) do not require prior authorization/preservice
  This section describes indications and patient parameters where prior authorization medical review is not required prior to rendering a drug administration service to our members. Coverage determination is made based on claim parameters.
  
  However, if the information required to pay a claim cannot be determined on the claim itself, a Provider's office may be contacted to acquire the information required for reimbursement.
  
  To assist providers, fax forms to provide such information may be available for particular drugs/drug categories. Information regarding access to these fax forms will also be included in this section. Fax forms may be sent with the claim for the drug to expedite coverage determination. 
  
  Please note: For expeditious claim payment, it is always recommended that providers obtain prior authorization before rendering services.
   
• Additional information
  This section may contain pertinent information helpful in clarifying coverage criteria and reference information that supports particular issues in coverage criteria. 
  
  Suggestions for patient monitoring parameters may be included this section. 
  
  This section will also contain other helpful medication information, such as black box warnings, bolded warnings from the package insert, or potential drug interactions or adverse effects.
   
• References
  This section provides references for the policy approved by the BSC Pharmacy and Therapeutics Committee. References include the medication package insert from the manufacturer. 
  
  When off-label uses are supported by a citation included, or approved for inclusion, in compendia defined by state and/or federal statute, references to those compendia will be included. 
  
  The references cited in each policy will be:
     1.  Brand Package Insert, xxx, Inc. version/month-year
     2.  AHFS First. http://ahfsfirst.firstdatabank.com
     3.  USP DI. http://uspdi.micromedex.com/index.html
     4.  Reference(s) to support statements in section (7).

Pharmacy contacts

PPO Medical Operations
    Phone: (800) 343-1691
    Fax: (916) 350-7798
 

HMO Medical Operations
   Phone: (800) 213-3465
   Fax: (916) 350-6677
 

Triage Claims Unit
    Fax: (916) 350-8866

Please use the above fax numbers for submitting authorization forms when services require prior authorization for coverage before services are rendered.
 

Pharmacy Services
(when requesting home self-injectables for members with an Outpatient Prescription Drug Benefit)
    Phone: (800) 535-9491
    Fax: (888) 697-8122