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October 2019

We’ll cover hemophilia drugs under the pharmacy benefit for most commercial members, starting Jan. 1

We’re changing how we cover hemophilia drugs for most of our commercial, non-Medicare members. Starting Jan. 1, 2020, if a member has Blue Cross Blue Shield of Michigan or Blue Care Network pharmacy coverage, all hemophilia drugs should be billed under their pharmacy benefits.

However, this change doesn’t affect all commercial members. For example, if a member has pharmacy coverage through a company other than Blue Cross or BCN, hemophilia drugs will continue to be covered under the medical benefit.

To determine whether this change applies to a specific member:

  • Review Blue Cross PPO member benefits in Benefit Explainer.
  • Review BCN HMOSM member benefits in web-DENIS.

We’ll notify affected members about these changes. Members don’t have to do anything. Their medication and treatment won’t change.

Here are answers to some frequently asked questions.

What changes will occur on Jan. 1, 2020?
For affected members, hemophilia drugs that are currently covered under the medical benefit will be covered under the pharmacy benefit. In addition:

  • Members will be limited to a 30-day supply of hemophilia drugs.
  • The hemophilia drug Hemlibra® will continue to require authorization.

When will the changes go into effect?
The changes will go into effect for dates of service on or after Jan. 1, 2020.

Which groups and members are affected?
This change affects most commercial Blue Cross PPO and BCN HMO members who have pharmacy coverage, including those covered by individual plans and those covered through groups with administrative service contracts.

ASC groups can opt out of the program. Groups that opt out will continue to use the medical benefit for hemophilia drugs.

The following groups and members aren’t affected:

  • HMO and PPO members with a carved-out pharmacy benefit
  • Medicare and Medicaid members
  • Groups with pharmacy benefits that involve limited and religious accommodations that cover only the pharmacy benefits mandated by the Affordable Care Act

How will this change affect members who are currently undergoing hemophilia therapy?
There won’t be any change to a member’s therapy. Drug selection, dosage and frequency will remain the same. Members will continue to receive care from their current providers.

We’re adding hemophilia drugs to the formulary as branded, nonspecialty medications. Depending on a member’s pharmacy benefits, copayments may increase for some members.

How will providers and specialty pharmacies know to bill the pharmacy benefit starting Jan. 1, 2020?
We’ll send letters to providers and specialty pharmacies about billing Blue Cross and BCN members under the pharmacy benefit, unless the members’ group has opted out of the hemophilia program.

If a hemophilia drug is processed under the pharmacy benefit and the group has opted out, a point-of-sale message will let the specialty pharmacy know immediately that the place of service isn’t covered. The provider or specialty pharmacy will be instructed to bill the medical benefit, as they did previously.

Why are we making this change?

Quality of care: We provide our members with access to the best health care at the lowest cost. By adding this drug class to the pharmacy benefit, we can continue to offer hemophilia therapy to our members while increasing the quality of care and possibly reducing the cost to the plan and to our members.

Better data: We’ll be able to get real-time data regarding units dispensed, dosing and the dates on which each member receives medication. This data isn’t always available under the medical benefit. In addition, we can see where the member is receiving therapy and direct him or her to higher-quality centers with better pricing.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.