Oct. 7, 2021

Beginning Jan. 1, 2022, the following specialty medications will no longer be covered or processed under the medical benefit for BlueCross BlueShield of South Carolina members who are subject to the Self-Administered Drug Block (SAB) component of the Specialty Medical Benefit Management (SMBM) program.

Additionally, those drugs noted with an asterisk (*) have an intravenous (IV) version in addition to the self-injectable version.  The IV version will, in addition to the self-administered version, be blocked under the medical benefit.  The member will need to fill the self-administered version under the pharmacy benefit.

Please note the following:

• These drugs are being added to the current SAB drug list of the SMBM program.  This is not a new program or initiative.
• Any member with a current or active prior authorization approval will be allowed to continue receiving their drug under their medical benefit until the expiration date of the authorization.
• When time for each member to renew their prior authorization, post Jan. 1, 2022, they will be required to move their therapy to the self-administered version of their drug.  The self-administered versions are covered under their pharmacy benefit.
• Members can fill the self-administered versions of their drug at Optum Specialty Pharmacy, our preferred specialty pharmacy.
• Pharmacy Management has notified impacted members by letter of the upcoming SAB benefit change for these targeted drugs.
• Members and providers have the ability to submit medical necessity documentation to seek approval for members to remain on their current IV therapy or continue to receive the self-injectable version under their medical benefit when appropriate via the standard appeals process.

About the SAB Program

Our SAB program is similar to those offered by many other payor/health plans that steer medications that have both an IV and self-administered version from coverage under the medical benefit to the pharmacy benefit.

Our line of business clients have requested we be more proactive in shifting share away from more costly medical administered drugs to the self-administered versions via the pharmacy benefit to help reduce their company drug cost exposure.

Members may experience a cost-share under the pharmacy benefit when moving to the self-administered version.

Providers and members do have a process, via appeals, to submit medical necessity rationale for allowing members to stay on their IV therapy under medical, when necessary.

If you have any questions, please contact Provider Education using the Provider Education Contact Form located on www.SouthCarolinaBlues.com or www.BlueChoiceSC.com.