Specialty Medications for Medicare Retirees 70/30 Plan

Many complex conditions are treated with specialty medications. Specialty medications are FDA approved drugs, which include biosimilars that are typically injectable medications administered either by you or a health care professional, and they often require spe​cial handling. Conditions commonly requiring specialty medications include:

 

  • Anemia 

  • Growth Hormone Deficiency 

  • Hemophilia 

  • Hepatitis C 

  • Multiple Sclerosis 

  • Oncology
  • Rheumatoid Arthritis 

Medications classified by the State Health Plan as specialty or Biosimilar medications meet all of the following conditions:

  • Treats complex medical conditions(s)

  • Requires frequent clinical monitoring, e.g. dosing adjustments

  • Requires special patient education, training and/or coordination of care

  • Generally prescribed by a specialist provider 

  • May require special handling, storage, and/or delivery requiremens

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  and Specialty Quantity Limit Drug List.

  • Self-administered (pharmacy benefit)

    • ​Coverage under the pharmacy benefit requires that the medications covered under the pharmacy benefit be ordered from CVS Specialty. To order, call 888-231-3124 between 8 a.m. and 8 p.m., Eastern Time, Monday through Friday. 

    • Patients administer these medications to themselves usually orally or by self-injection.

    • To obtain a prior authorization, providers may contact CVS Caremark at 866-387-2573.

  • ​​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.

Using CVS Specialty Pharmacy

CVS Specialty Pharmacy, 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 CVS Specialty for all non-acute, self-administered specialty medications filled under the pharmacy benefit, excluding medications used to treat cancer. If a member uses a pharmacy other than CVS Specialty Pharmacy to purchase any of the specialty medications​ listed, they will be responsible for paying the total amount of the prescription at the time of purchase.

Services provided by CVS Specialty Pharmacy 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 CVS Specialty. There are two options to contact CVS Specialty:

  • OPTION 1 – Call CVS Specialty Pharmacy:

    • Step 1: Call CVS at 888-231-3124 between 8 a.m. and 8 p.m., Eastern Time, Monday through Friday.

    • Step 2: CVS will contact your provider and start the pharmacy transition arrangements so that you can continue receiving the medications you need.

    • Step 3: CVS 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 888-231-3124.

    • Step 2: CVS Specialty will call you back to arrange for expedited delivery of your medications at a time that is convenient for you.

    • To learn more about CVS Specialty Pharmacy services, call 888-231-3124 or visit Caremark.com.