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Blue Cross Blue Shield of Rhode IslandCommercial · Coverage · Physician · RI · Oncology, Rheumatology, Ophthalmology +3 moreHigh impact

Drugs moving from the specialty pharmacy benefit to the medical benefit 4/1/21

Act
by Apr 1, 2021
Effective date
Apr 1, 2021
Identified
Jun 19, 2026

Summary

Effective April 1, 2021, BCBSRI moved 15 specialty drugs from the specialty pharmacy benefit to the medical benefit, making them eligible for buy-and-bill with specific HCPCS codes. These drugs no longer need to be obtained from AllianceRx/Walgreens Specialty Pharmacy and can be billed directly by providers using the designated HCPCS codes.

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What to do

by Apr 1, 2021 · 4 steps
01Billing team must update system to bill these 15 specialty drugs using the specific HCPCS codes provided (J3262, J0585, J0586, etc.) instead of routing through specialty pharmacy.
02Update encounter forms with new HCPCS codes for buy-and-bill procedures.
03Add administration codes as previously utilized.
04Verify prior authorization status through CoverMyMeds, fax, or mail for drugs requiring MDR program approval.

Codes mentioned

J3262J0585J0586J0178J2778J9217J1950J0897J9312Q5119J1602J3315Q5115J2323J3396J0588J9202

Original notice

Drugs moving from the specialty pharmacy benefit to the medical benefit 4/1/21
bcbsri.com · Always check the source before changing claims.
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Related changes

See all Blue Cross Blue Shield of Rhode Island changes →
Step therapy drug update for Medicare – Effective January 1, 2022HighEffective Jan 1, 2022 · PhysicianChanges being made to the Medical Drug Review (MDR) programMediumEffective Apr 1, 2022 · Physician / FacilityMedical drug review updates effective April 1, 2022MediumEffective Apr 1, 2022 · Physician / FacilityCPT® and HCPCS Level II code changesHighEffective Jan 1, 2019 · Physician / FacilityBrowse every Blue Cross Blue Shield of Rhode Island change in the policy list

Related policy hubs

Blue Cross Blue Shield of Rhode Island policiesRI policy changesOncologyRheumatologyOphthalmologyNeurologyEndocrinologyGastroenterologyCode J3262Code J0585Code J0586Code J0178Code J2778Code J9217Code J1950Code J0897Code J9312Code Q5119Code J1602Code J3315Code Q5115Code J2323Code J3396Code J0588Code J9202

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