Some prescription medications may require specialty handling, administration, or require ongoing clinical monitoring. These medications are most commonly used for complex, chronic conditions, and are often very costly. Blue Cross NC provides coverage under its medical and prescription drug benefits for these medications in accordance with benefit guidelines.
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.
Some of these covered medications are self-administered and are covered only under the pharmacy benefit. Self-administered medications do not require professional administration. Examples of self-administered medications are tablets and liquids taken by mouth and injections given subcutaneously (under the skin). Medical supervision and/or instruction may be required for certain injectable medications.
Specialty drugs are not limited to a specific copayment or coinsurance tier but can be found in all formulary tier levels. Review our specialty drug list* to see if your drug must be filled at one of the specialty network pharmacies.
*The specialty drug list is subject to change and is updated regularly.
Individuals – Under 65 and Fully Insured group members who currently have pharmacy benefits through Blue Cross NC who use specialty drugs must use the specialty pharmacy network in order for their prescriptions to be covered. Certain Commercial group members will be required to use Accredo for their specialty pharmacy needs.
Specialty Pharmacy Network
If you are prescribed a specialty drug, you may have to use a certain specialty pharmacy to obtain your medication. Preferred specialty pharmacies vary by plan. When you use a pharmacy participating in the specialty pharmacy network, you will receive the following services:
- Educational materials and support to manage your condition
- Free delivery of medication, often by the next day to the location of your choice
- Supplies to administer your medication including sharps container, syringes, and injection site supplies, as necessary
- Access to a pharmacist or nurse 24/7
- Working with you to assure you are taking your medications correctly and being compliant with the drug therapy
- Clinical support for dosing and potential side effects
- Automatic coordination of refills
To locate a specialty network pharmacy near you, please search the Specialty Pharmacy List.
The Blue Cross NC Hemophilia Network — a sub-network within the primary Specialty Pharmacy Network List — 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.
If you have any questions about the Specialty Pharmacy Network, please call the number listed on the back of your Blue Cross NC member ID card.