The Specialty Pharmacy Program supports the health care provider/patient relationship to help better manage rare and complex chronic conditions. Specialty medications can be covered under the pharmacy benefit, the medical benefit or both benefits, depending on the benefit structure applied to the coverage policy.
Pharmacy benefit medications are typically self-administered by the patient or a caregiver, after filling the prescription through a specialty pharmacy. These medications are labeled for self-administration by the Food and Drug Administration but may require some instruction to the patient or caregiver.
Typically, medications administered orally, topically or through subcutaneous injection by the patient or a caregiver after receiving instruction are covered under the pharmacy benefit.
Medical benefit medications are typically administered by a health care professional in a health care setting and monitored by a health care professional. They’re shipped from a specialty pharmacy directly to a health care setting (i.e., sourced) or a provider may purchase them directly using their standard distribution process (i.e., buy and bill).
The medication is typically administered in a physician office, at home, in an ambulatory infusion suite or in an outpatient facility. These medications can be administered by infusion, injection or intramuscularly with the help of an infusion nurse.
To identify the applicable benefit and locate a contracted specialty pharmacy vendor, click here to download: Provider Vendor Assistance List - Specialty Pharmacy.
Inclusion in this list does not indicate a drug is covered by a particular plan. Any drug may be subject to other requirements including but not limited to Exclude at Launch and or Review at Launch.