Specialty Pharmacy Frequently Asked Questions
- What are specialty medications?
- What changes are being made in my pharmacy benefit for specialty medications?
- The increase in copay for specialty medications is more than I used to pay. Is this because members can only use the Accredo pharmacy?
- Does this copay change apply to specialty medications that are administered in my doctor’s office?
- Has the out-of-pocket maximum for pharmacy changed?
- Do all specialty medications have to be purchased through Accredo?
- Why do I have to use Accredo to obtain my specialty medications?
- Whom do I contact for more information concerning specialty Medications?
What are specialty medications?
Many complex conditions are treated with specialty medications. Specialty medications are typically injectable medications administered either by you or a health care professional, and they often require special handling. Medications classified by the Plan as specialty medications meet all of the following conditions:
- Have unique uses for the treatment of complex diseases
- Require special dosing or administration
- Require special handling
- Are typically prescribed by a specialist provider
- Exceed $400 cost to the Plan per prescription
What changes are being made in my pharmacy benefit for specialty medications?
Beginning July 1, 2009, State Health Plan members must use Accredo for all non-acute specialty medications currently filled at retail pharmacies and covered under the pharmacy benefit. If a member uses a pharmacy other than Accredo to purchase any of the non-acute specialty medications listed, they will be responsible for paying the total amount of the prescription at the time of purchase. For acute specialty medications (those needed immediately) and cancer medications, members will not be required to use Accredo.
In addition to the requirement for using Accredo, as of July 1, 2009, the copay for all specialty medications will require the member to pay 25% coinsurance up to $100, for each 30-day supply.
The increase in copay for specialty medications is more than I used to pay. Is this because members can only use the Accredo pharmacy?
No. The copay change is not related to the fact that Accredo is providing specialty pharmacy services.
The copay increase was implemented to help control the rising cost of specialty medications, which average over $1500/month, and to maintain an affordable prescription drug benefit for Plan members. However, in this process some members will see their out-of-pocket expenses increase due to the copay change.
As an example, most specialty medications are brand name medications and were previously in Tier 4, with a $50 copay. A few specialty medications, such as Ribavirin, are generics, but cost the plan over $400 for a 30-day supply. The copay for all specialty medications will be increasing from $10/month to 25% coinsurance (up to $100/month).
Does this copay change apply to specialty medications that are administered in my doctor’s office?
No. The requirement to use Accredo only applies to specialty medications currently covered under the pharmacy benefit and obtained from a retail pharmacy. This change does not apply to specialty medications obtained in a provider’s office and covered under the medical benefit.
Has the out-of-pocket maximum for pharmacy changed?
No. The out-of-pocket maximum for pharmacy remains at $2,500 per benefit year. If you spend more than $2,500 for your prescriptions between July 1 and June 30, all additional prescriptions will be covered at 100%.
Do all specialty medications have to be purchased through Accredo?
No. Acute specialty medications do not have to be purchased through Accredo; nor do medications used to treat cancer. You have the option of using either Accredo or your local in-network pharmacy.
- Acute specialty medications are those that are needed immediately, such as for infertility or a blood clot.
- Most specialty medications are those needed for chronic conditions.
- The requirement to use Accredo only applies to non-acute specialty medications currently covered under the pharmacy benefit and obtained from a retail pharmacy. This change does not apply to specialty medications obtained in a provider’s office and covered under the medical benefit.
Why do I have to use Accredo to obtain my specialty medications?
The State Health Plan is implementing these changes for specialty medications in order to maintain high standards of member care and safety. Accredo deals exclusively with providing medications to treat complex conditions. Accredo provides:
- Answers to your questions or concerns about your specialty medications from a pharmacist 24 hours a day, 7 days a week
- Personalized counseling from a team of registered nurses and pharmacists
- Coordination of home care and other healthcare services, when appropriate
- Expedited, scheduled delivery of your medications at no extra charge
- Up to a 30-day supply of your specialty medication for just one copay
Whom do I contact for more information concerning specialty Medications?
It’s easy to get started using Accredo. You have the option of contacting Accredo directly, or you may prefer to have your provider contact Accredo regarding your prescription.
- If you would like to contact Accredo yourself:
Step 1: Simply call the Accredo Specialty pharmacy toll-free at 1-800-803-2523 between 8:00 a.m. and 8:00 p.m., Eastern time, Monday through Friday.
Step 2: Accredo will contact your provider and start the pharmacy transition arrangements so that you can continue receiving the medications you need.
Step 3: Accredo will call you back to arrange delivery of your medications at a time that is convenient for you.
- If you would like your doctor to call:
Step 1: Give your provider your member ID number (shown on your prescription drug ID card), and ask him or her to call 1-800-987-4904.
Step 2: Accredo will call you back to arrange for expedited delivery of your medications at a time that is convenient for you.
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