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. Physician-administered injectables
   HMO members – prior authorization through IPA or HMO Medical Operations
   PPO members – prior authorization through PPO Medical Operations
   Medi-Cal members – prior authorizations through Blue Shield Promise Medical Operations
    
2. Home health/infusion injectables
   HMO members – prior authorization through delegated IPA or HMO Medical Operations
   PPO members – prior authorization through PPO Medical Operations
   MediCal members – prior authorization through Blue Shield Promise Medical Operations
    
3. Self-administered products (including home self-injectables)
   HMO members – prior authorization through Blue Shield of California (BSC) Pharmacy Services
   PPO members – prior authorization through BSC Pharmacy Services
   
   

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). This section may also contain information about specialty pharmacy distributors when applicable.
    
• Coverage criteria 
  • The following condition(s) require prior authorization/preservice
    This section describes the medical necessity requirements for indications that require prior authorization review. Coverage decision is made prior to drug administration.
  • The following conditions(s) do not require prior authorization/preservice
    This section describes the parameters where prior authorization review is not required prior to drug administration. Coverage decision is made based on previous claim history.
  
  

  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.
  
  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 to support coverage and reference information that supports a particular condition/indication. 
  
  Suggestions for patient monitoring parameters may be included this section. 
  
  This section will also contain other helpful medication information, such as boxed warnings from the package insert, or potential drug interactions or adverse effects.
   
• References
  This section provides references used to support the drug policy which has been approved by the BSC Pharmacy and Therapeutics Committee. References include the medication package insert from the manufacturer and medical evidence (e.g. peer-reviewed literature, treatment guidelines, etc).
  
  When off-label uses are supported by the medical evidence (e.g. peer-reviewed literature, treatment guidelines).or 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-Drug Information®. Available by subscription at http://www.lexi.com
     3.  DrugDex®. Available by subscription at http://www.micromedexsolutions.com/home/dispatch
     4.  Reference(s) to support requirements in coverage criteria

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 self-adminstered products for members with an Outpatient Prescription Drug Benefit)
    Phone: (800) 535-9491
    Fax: (888) 697-8122