Specialty Pharmacy Benefit Clarifications
Many complex conditions are treated with specialty medications. Specialty medications are FDA approved drugs that are typically injectable medications administered either by you or a health care professional, and they often require special handling. Conditions commonly requiring specialty medications include:
- Growth Hormone Deficiency
- Hepatitis C
- Multiple Sclerosis
- Rheumatoid Arthritis
Medications classified by the State Health 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
The State Health Plan designates between self-administered specialty medications and provider-administered specialty medications for benefit coverage. Please refer to the Specialty Drug List.
Self-administered (pharmacy benefit)
- Covered under the pharmacy benefit and subject to 25 percent coinsurance per 30 day supply up to $100 maximum.
- Patients administer these medications to themselves usually orally or by self-injection.
- To obtain a prior authorization, providers may contact Medco at 800-417-1764.
- Coverage under the pharmacy benefit requires that the medications designated with a "†" symbol be ordered from Accredo. To order, call toll-free 877-988-0059 between 8 a.m. and 8 p.m., Eastern time, Monday through Friday – or just have your doctor contact Accredo at 800-987-4904.
Provider-administered (medical benefit)
- Covered under the medical benefit and subject to office charges.
- Medications are usually administered by intramuscular injection or intravenous injection or infusion.
- Ordered by a provider and administered under provider supervision in an office, outpatient setting or through home infusion.
- To obtain prior authorization providers may contact Blue Cross and Blue Shield of North Carolina customer service at 888-234-2416.
Accredo, the State Health Plan's specialty pharmacy, deals exclusively with supplying medications to treat complex conditions and provides a high level of care for patients with chronic or serious conditions, who take medications that require injection, special handling and monitoring.
Plan members must use Accredo for all non-acute, self-administered specialty medications filled under the pharmacy benefit and marked on the specialty drug list with the "†" symbol. If a member uses a pharmacy other than Accredo to purchase any of the specialty medications listed and marked with a "†", they will be responsible for paying the total amount of the prescription at the time of purchase.
Services provided by Accredo include:
- An on-call pharmacist to answer questions 24 hours a day, 7 days a week
- Personalized counseling from a team of registered nurses and pharmacists
- Coordination of home care and other health-care services, when appropriate
- Expedited, scheduled delivery of your medications at no additional cost
- Refill reminder call
It's easy to get started using Accredo. There are two options to contact Accredo:
- OPTION 1 – Call Accredo specialty pharmacy:
- Step 1: Call Accredo toll-free at 877-988-0059 between 8 a.m. and 8 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.
- OPTION 2 – Have your provider call:
- Step 1: Give your provider your member ID number (shown on your State Health Plan ID card), and ask him or her to call 800-987-4904. Your provider may also order your specialty medication by accessing the Accredo website, completing the condition specific form with the requested information, and then faxing the completed form to Accredo.
- Step 2: Accredo will call you back to arrange for expedited delivery of your medications at a time that is convenient for you.
To learn more about the specialty pharmacy benefit, view the Frequently Asked Questions. To learn more about Accredo specialty pharmacy services, call 877-988-0059 or visit the Accredo website.