Very High Cost Drugs and Therapies

As new drugs and technologies become available, many of these treatments come with a very high cost. In an effort to control rising health insurance premiums, while continuing to make these therapies available to our members, certain drugs or therapies are subject to specific benefit, administration, and billing requirements.

There are specific benefit requirements for these very high cost drugs and therapies. These requirements may steer members to more cost-effective, yet equally safe administration facilities, may require billing from specific providers, or may require billing under either the pharmacy or medical benefit. However, they must be billed by a facility or specialty pharmacy that is directly contracted with BCBSKS, either through medical contracts or Letter of Agreement.

Our case management team assists our members with ensuring these requirements are met. Learn more about case management and how their program benefits our members.

The following medications require submission of a Prior Authorization form to BCBSKS.

Policies can be found on the BCBSKS Medical Policies web page. If no therapy-specific policy exists, the therapy is reviewed to FDA label.