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.
Frequently Asked Questions about Specialty Benefits
What are the benefits of receiving specialty medications from a specialty pharmacy?
The Specialty Pharmacy Program is designed to support your treatment plan for specialty conditions and facilitate the physician/patient relationship.
This program can help your patient receive cost-effective care by finding out if his or her medication has specific utilization management requirements or an optimal place of service. This program also helps your patients use the right medications for their condition. The participating specialty pharmacies have specifically-trained pharmacists on staff to help support member education and medication compliance.
How can my patient enroll in a specialty pharmacy program?
Your patient can contact the specialty pharmacy directly to enroll in a clinical management and medication adherence program.
A specially-trained pharmacist routinely assesses your patient's specialty medication regimen to make sure it is achieving the desired results. The pharmacist may ask you to clarify a diagnosis or dosage. They may also notify you of an adverse drug effect, drug interaction, adherence issue or depression screening outcome.