How specialty drugs are classified
What qualifies a specific drug or therapy to be classified as a specialty pharmaceutical is not clearly defined. However, the following factors help define a specialty drug:
- The drug(s) requires special handling;
- The drug(s) has a limited distribution and can only be filled at certain pharmacies;
- If the drug(s) treats rare disease(s);
- Or if the drug requires ongoing clinical assessment and/ or monitoring of side effects.
Specialty drugs are most commonly used for chronic diseases, such as rheumatoid arthritis and multiple sclerosis. Most specialty drugs are injectable and require special handling and administration. Specialty drugs are not limited to a specific copayment or coinsurance tier but can be found in all formulary tier levels. Review our Specialty Pharmacy Drug List (PDF) to see if a drug must be filled at one of the specialty network pharmacies.
Specialty drugs can be covered under a member’s pharmacy benefit or medical benefit, depending on the administration (self-administered or provider-administered).
Services provided by specialty pharmacies
If a specialty drug is prescribed, members may have to use a certain specialty pharmacy to obtain their medication. Preferred specialty pharmacies vary by plan. Participating specialty pharmacies will provide the following services:
- Educational materials and support to manage the member’s condition
- Free delivery of medication, often by the next day to the location of the member's choice
- Supplies to administer medications including sharps container, syringes, and injection site supplies, as necessary
- Access to a pharmacist or nurse 24/7
- Working with members to ensure they are taking their medications correctly and being compliant with the drug therapy
- Clinical support for dosing and potential side effects
- Automatic coordination of refills
Review the specialty drug list to see if a drug must be filled at one of the specialty network pharmacies. To locate a participating specialty network pharmacy, please search the Specialty Pharmacy List (PDF).
This does not impact Blue Medicare Rx℠, North Carolina State Health Plan (SHP) or Federal Employee Program (FEP) members.
Office-administered injectable drugs
The specialty pharmacy network is also contracted to provide specialty drugs for provider administration to Blue Cross NC members. These medications are typically covered under the member’s medical benefit. These pharmacies bill Blue Cross NC directly, making administering specialty injectable drugs easier for providers and members.
The Office-Administered Specialty Pharmacy Network is available to supply providers with select specialty injectable drugs for the treatment of Blue Cross NC patients. With this network, providers can have member-specific, dose-specific drugs delivered directly to their office, and the network vendors will bill Blue Cross NC directly for the drug.
The Office-Administered Specialty Pharmacy Network will:
- Improve access to and simplify the process of obtaining select specialty injectable drugs
- Remove the financial risk providers may have incurred when supplying specialty injectable drugs in the past
- Reduce office paperwork
- Streamline the submission of specialty injectable drug claims
Before you use the Office-Administered Specialty Pharmacy Network, remember:
- Use of the Office-Administered Specialty Pharmacy Network is voluntary
- Network vendors will bill Blue Cross NC directly for the injectable drug
- If a member-specific, dose-specific injectable drug is ordered from a network vendor - do not file a claim with Blue Cross NC for the drug. The vendor will bill Blue Cross NC directly.
Be advised that certain self-administered drugs have been excluded from Blue Cross NC's medical benefits but are covered under the prescription drug benefit. In instances when a patient requires assistance with the administration of these drugs, providers can continue to file for administration fees; however, Blue Cross NC will no longer provide reimbursement to physicians for the designated self-administered drugs.
Medicare Supplement subscribers are excluded. Please continue to obtain injectable drug for these patients through your current process.
The following office–administered specialty drugs may have medical policies or require prior plan approval. For each drug class, each ingredient name is listed with its brand name equivalents in parentheses.
Self–administered specialty drugs covered under the prescription drug benefit must be filled by a pharmacy in the Specialty Pharmacy Network. Certain self–administered drugs have been excluded from Blue Cross NC's medical benefits but are still covered under the prescription drug benefit.
Some of these drugs listed below may require prior review.
When filing a specialty pharmacy drug with an unclassified HCPCS code, the appropriate NDC # must be included on the claim.
These Specialty Pharmacy Drugs (PDF) are covered under the medical benefit and administered in the provider office. This list applies to all participating in-network providers.
The Blue Cross NC Hemophilia Network creates an improved and integrated experience for members that self-administer their hemophilia drugs by allowing specialty pharmacies that meet specific clinical and other criteria to dispense those drugs. The goal of the network is to proactively manage our members with hemophilia in order to lower overall costs and create an individualized and exceptional member experience.
Effective April 1, 2021, all specialty medications for the treatment of hemophilia and other bleeding disorders must be dispensed through a pharmacy participating in this network. All commercial members, including self-insured members who have an exclusive specialty pharmacy provider, must fill hemophilia medications at a pharmacy participating in the new hemophilia network.
View a list of pharmacies participating in our Hemophilia Network through our Specialty Pharmacy List (PDF).
Free Market Health
Blue Cross NC has partnered with Free Market Health (FMH) to launch an innovative specialty pharmacy program for our ACA and Commercial members. The new program orchestrates and optimizes the specialty drug fulfillment process to improve care quality, open fair access to our network pharmacies, and decrease drug costs.
- To increase process efficiency, improve care quality, and decrease the time it takes for members to receive their medications.
- To offer transparent and fair access to authorized referrals to our specialty pharmacy network and reward high-quality care.
- To leverage dynamic market rates at the referral level to ensure specialty drugs remain affordable for our members.
- Upon an approved prior authorization for select specialty drugs, FMH receives the referral for management.
- FMH orchestrates Blue Cross NC's program configuration and evaluates the referral based on drug, disease, member and plan attributes.
- The referral, inclusive of care accountabilities and incentives, is matched to an in-network specialty pharmacy best-suited to service the referral.
- The assigned specialty pharmacy will reach out to the prescriber to obtain the prescription and onboard the member to initiate service.
Specialty pharmacies participating in the FMH program gain:
- Expanded access to authorized specialty drug referrals
- Control over the types of referrals they pursue
- Time and money back previously spent on misdirected referrals
- Additional reimbursement for high quality care
To participate in the FMH program and continue servicing Blue Cross NC ACA and Commercial members after October 1, 2023, network pharmacies must sign an addendum/contract with Free Market Health.
The specialty pharmacy matched to the referral will reach out to the prescriber office to obtain the prescription, and prescribers may notice new specialty pharmacies servicing their patients. The assigned pharmacy has Blue Cross NC’s authorization to service the referral.
The specialty drug referral process under FMH is managed and streamlined to decrease the time it takes for members to receive their medications, monitor first fills, and reduce medication abandonment for members in need of and authorized for a specialty drug. Members are also serviced by a specialty pharmacy capable and accountable to meet their needs with focused care management that improves the patient experience.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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