Medication claims policies and guidelines
Behavioral health specialty medications
Behavioral Health specialty medications are plan risk as well as the UM review. Prescribed medications, if medically necessary, will be dispensed by a Blue Shield contracted Specialty Pharmacy. The behavioral health specialty medications list will be updated by Blue Shield Pharmacy Services when there are changes to the list. View a listing of the behavioral health specialty medications below:
- Q1 2024 Behavioral health specialty medications
- Q4 2022 Behavioral health specialty medications
- Q2 2021 Behavioral health specialty medications
Gene and cell therapy agents
The gene and cell therapy agent (including CAR-T) list will be updated by Blue Shield Pharmacy Services when there are changes to the list. Available gene and cell therapies administered in either an inpatient setting or outpatient setting (non-office) can be found on the listing below:
- Q3 2024 Gene and cell therapy agents
- Q2 2024 Gene and cell therapy agents
- Q1 2024 Gene and cell therapy agents
- Q4 2023 CAR-T agents
- Q3 2023 CAR-T agents
- Q2 2023 CAR-T agents
Gene and cell therapies that are approved for administration in an office are also identified on the Richman Injectables list below.
Richman Injectables
Section 1375.8 of the California Health and Safety Code (commonly referred to as the Richman Bill) prohibits Blue Shield from requiring Group to assume financial responsibility for the following injectable drugs when administered in the office of a physician and surgeon to a member enrolled in a commercial benefit program, or prescribed by a physician and surgeon for self-administration by a member enrolled in a commercial benefit program:
- Injectable chemotherapeutic medications and injectable adjunct pharmaceutical therapies for side effects
- Injectable medications or blood products used for hemophilia
- Injectable medications related to transplant services
- Adult vaccines
- Self-injectable medications
- Other injectable medication or medication in an implantable dosage form costing more than two hundred and fifty dollars ($250) per dose.
Most drugs in this listing are accessed through a physician provider office, infusion provider or delivery to physician office by specialty pharmacy provider; dependent on the contract between Blue Shield and the IPA/medical group.
Many drugs covered under the medical benefit require prior authorization based on the Blue Shield Drug Policies approved by the Blue Shield Pharmacy and Therapeutics Committee. Prior authorization is delegated to the IPA/medical group.
Members must obtain their hemophilia factor through our exclusive hemophilia network pharmacy Red Chip (via select Hemophilia Treatment Centers), Accredo, and CVS Caremark®.
View current and past listings of Richman Injectables below:
Claims resources
Ancillary claims filing guidelines
Review claim submission requirements for Blue Shield of California labs, specialty pharmacy and DME providers.
Special guidelines for claim forms
Special guidelines for CMS 1500 and UB-04 claims to help physicians submit these forms properly and process claims efficiently.
Enroll in EDI
Learn how to submit all of your claims and receive your payments electronically for faster processing and payment using electronic data interchange (EDI).
Medication policy
Read about our medication policy for injectable and office-administered drugs.
Payment policies and rules
Read an overview of payment processing policies and rules.
National Drug Code requirements for physician administered drugs
Find requirements and drug list for claims and encounters for Promise Medi-Cal and Cal MediConnect members.