CommercialCoverageMedium impact
Drugs moving from the specialty pharmacy benefit to the medical benefit
Blue Cross Blue Shield of Rhode Island·RI · Oncology, Rheumatology, Gastroenterology +1 more·Physician / Facility
Effective date
Oct 1, 2019
We identified it
Jun 20, 2026
Summary
Effective October 1, 2019, specific specialty drugs including immune globulins, Entyvio, Remicade, Inflectra, and Renflexis moved from specialty pharmacy benefit to medical benefit for commercial members. These drugs can now be billed under buy-and-bill using specified HCPCS codes but still require prior authorization through Prime Therapeutics.
Action Required
By October 1, 2019: Billing team must update system to enable buy-and-bill for listed specialty drugs using specified HCPCS codes (J1556, J3380, J1572, etc.) and include required administration codes. Continue obtaining prior authorization through CoverMyMeds, fax (1-855-212-8110), or mail to Prime Therapeutics before administering these drugs. Update encounter forms to reflect medical benefit billing instead of pharmacy benefit.