Name of Manual - Blue Cross and Blue Shield of Minnesota

Coding Policies and Guidelines (Pharmacy Services)
Prior Authorization The prescribing physician must obtain prior authorization through
Blue Cross’s medical review area for certain drugs. Some
examples of drugs requiring prior authorization include infertility
drugs and growth hormones.
For a complete listing, refer to the Blue Cross and Blue Shield of
Minnesota Medical Policy Update. To view medical policies go to
providers.bluecrossmn.com and select “Medical policy” under
“Tools & Resources.”
For drugs that require a prior authorization, complete a Minnesota
Uniform Form for Prescription Drug Prior Authorization (PA)
Requests and Formulary Exceptions.
Injectable Drugs Most prescription benefit plans allow injectable processing online.
Be sure to use the appropriate NDC and submit your claim
electronically to the processor.
Pharmacies Submitting
Claims for DME
For durable medical equipment, the pharmacy must follow the
normal process for claims submission utilizing the electronic 837P
claim format.
The Aware Agreement, Article III, Section A, "Scope of Services"
states: “Provider shall provide Health Services to Subscribers for
eligible Prescription Drugs which are authorized by a valid
prescription.” This section also includes the dispensing of durable
medical equipment (DME) to Blue Cross subscribers.
It is the responsibility of the participating pharmacy to submit the
claims for all such eligible services to Blue Cross on behalf of the
subscriber. After the claim is processed by Blue Cross, you will be
notified of the proper amount to bill the subscriber, if any balance
remains due from the subscriber.
It is also the responsibility of all participating providers to abide by
all other terms and provisions of the agreement including, but not
limited to, the administration of the coordination of benefits
provisions. This process is detailed in Article III, Section M,
Coordination of Benefits.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/09/11)
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