Provider-Administered Medical Exclusions
DESCRIPTION
The purpose of this document is to establish a policy for the exclusion of provider-administered pharmacy products under the medical benefit. Following approval of a provider-administered pharmacy product by the Food and Drug Administration, the BlueCross BlueShield of Tennessee (BCBST) Pharmacy and Therapeutics (P&T) Committees engage in a New Drug Therapy Review. This review evaluates the product’s effectiveness, safety, and affordability and determines coverage parameters and a utilization management strategy.
After completing a clinical review, some products may be moved to excluded status and not be covered for BCBST. Products may be excluded from coverage for a variety of reasons, including but not limited to, at least one of the following:
Multiple options exist within a therapeutic category
Product demonstrates little to no advantage in safety or efficacy over existing product(s)
Data and/or clinical literature is limited or lacking
Providers are encouraged to review the BCBST Medical Exclusion list periodically. BCBST reserves the right to revise, add, or remove products at any time.
Members are encouraged to discuss covered options with their provider if using one of our excluded products. If members choose to remain on an excluded product, benefits may not apply, and the member may be responsible for the entire cost of the drug therapy.
POLICY
All new to market provider-administered pharmacy products will be excluded from coverage until the P&T committees complete the New Drug Therapy Review. Once the New Drug Therapy Review has been completed, provider-administered pharmacy products may move to a covered or excluded status.
A provider-administered specialty pharmacy product is not covered unless and until it is included on BCBST’s online list of provider-administered specialty pharmacy products, which is available at the following link: https://www.bcbst.com/docs/pharmacy/provider-administered-specialty-pharmacy-list.pdf.
Provider administered pharmacy products that are excluded from coverage for BCBST may be referenced on BCBST’s online list of medically excluded products, which as of the effective date of this policy, is available at https://www.bcbst.com/docs/pharmacy/medical-exclusions-drug-list.pdf.
ORIGINAL EFFECTIVE DATE: 1/1/2023
MOST RECENT REVIEW DATE: 1/1/2023
ID_Pharmacy
This document has been classified as public information.