April 2021
Specialty Pharmacy Update: Changes to Select Medication List, Effective June 1, 2021
National Drug Codes (NDCs) and NDC data are required by Blue Cross and Blue Shield of Illinois (BCBSIL) for drugs billed under the medical benefit on professional/ancillary electronic (ANSI 837P) and paper (CMS-1500) claims. When you bill with NDCs, BCBSIL can identify and reimburse you for the individual medication that was prescribed (instead of for a range of NDCs within the applicable procedure codes).
With this capability in mind, BCBSIL’s Select Medication List includes specific drugs within particular classes or categories, based on safety and cost effectiveness. Choosing a drug from the Select Medication List and billing for it with the appropriate NDC may result in a higher reimbursement rate than the rate applied for other, non-listed drugs in the same class.
The Select Medication List is posted in the Specialty Pharmacy section, under the Related Resources. Currently, it includes two injections from the viscosupplementation class that are used primarily for osteoarthritis knee pain relief. Upcoming changes are noted below.
The products on the Select Medication List will be updated effective June 1, 2021.
Euflexxa® will be removed as a viscosupplement from the Select Medication List. It will be replaced by Orthovisc®. Synvisc-One® will remain on the Select Medication List. Please note reimbursement may change to reflect these product changes.
The listing of any particular drug or classification of drugs is not a guarantee of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, terms, conditions, limitations and exclusions set forth in the member’s policy or benefits document. Members should refer to their contract 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.
Euflexxa is a registered trademark of Ferring B.V. Orthovisc is a registered trademark of DePuy Synthes. Synvisc-One is a registered trademark of Genzyme Corporation.