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Medications You Administer

Medications covered by medical benefits that you administer

If you are administering medication to a member in your office or in an outpatient setting, we encourage you to take these steps:

Step Check member benefits and eligibility. Use a self-service technology like Online Services or contact us.

Commercial members do not have medical benefits for these medications and some employers customize benefits.
 Injectable specialty medication coverage (medical policy 071)

Step Determine whether authorization for the medication is required.

Commercial members:

View our medical policies for the medication:
 Medical Utilization Management (MED UM) & Pharmacy Prior Authorization Policy (033)
 Medical Benefit Prior Authorization Medication List (034)

Learn how to request prior authorization.

Federal Employee Program members:
For high-cost medications that do not require pre-certification or prior approval, you can request an Advanced Benefit Determination to find out the member’s medical benefits for the medication before you administer it. 

Fax in your written request, along with relevant medical record documentation, to 1-888-282-1315. You must write "Advanced Benefit Determination" on the front of your cover page.

Medicare Advantage members:
We require step therapy and prior authorization for certain medications covered under our Medicare HMO Blue and Medicare PPO Blue members' Part B medical benefits.

2021 Medicare Advantage Part B Step Therapy Criteria

Medicare Advantage Part B Step Therapy Medical Policy 020

Prior authorization is required for these medications when administered in outpatient settings under our Medicare Advantage members’ Part B medical benefits.

Medicare Advantage Part B Medical Utilization (MED UM) Policy 125

Learn how to request prior authorization.

Step Perform the service and submit your claim.