This program helps deliver specialty and complex care medications directly to providers to treat patients’ complex, chronic or rare medical conditions. They are only available at select pharmacies due to their limited or exclusive access. They have unique storage and shipment requirements. Patients taking these medications need to follow a clinical care plan that often changes dosing, monitors clinical results and/or offers counseling, education or individualized disease and drug care therapy.
Specialty and complex care medication coverage is based on the member's benefit. Prior Authorization or Predetermination approval may still apply to specific specialty and complex care medications. In accordance with their benefits, some members may be required to use an in-network specialty and complex care pharmacy, or be subject to a split fill program, in order for benefits to apply. For more information about medical criteria, please refer to the Medical Policies.
Note: Depending upon administration (physician-administered or self-administered), the member’s plan will determine which benefit (medical coverage or pharmacy coverage) will cover the medication. Please call the number on the member’s ID card to verify coverage, or for further assistance or clarification on your patient’s benefits.
Self-Administered Specialty and Complex Care Medications
Specialty and complex care medications that are U.S. Food and Drug Administration approved for self-administration are typically covered under the member’s pharmacy benefit. Some members’ plans may require them to obtain these medications from an in-network specialty and complex care pharmacy* for benefit consideration.
Blue Cross and Blue Shield of Illinois contracts with Accredo to obtain specialty and complex care medications approved for self-administration. To contact Accredo, call 833-721-1619, e-prescribe the prescription** or fax the general referral form . You can visit accredo.com/prescribers for referral forms by therapy and more information. Accredo also has a prescriber portal for you to monitor the status of all of your Accredo patients.
BCBSIL also contracts with select specialty and complex care pharmacies (Pharmacy Match) to obtain certain self-administered specialty and complex care medications for our members.
Physician-Administered Specialty and Complex Care Medications
BCBSIL contracts with select specialty and complex care pharmacies to obtain specialty and complex care medications for physician administration to our members. These medications are typically covered under the member’s medical benefit.
By obtaining these specialty and complex care medications from these preferred pharmacies*, providers may benefit from:
- Integrated coordination of coverage between the member, provider and BCBSIL
- No up-front acquisition cost to providers for office-administered specialty and complex care medications
- Convenient delivery of medication to location of choice (i.e., provider’s office, site of practice, home infusion)
- Injection supplies with every shipment, including alcohol swabs, needles and syringes (if applicable)
- Automatic coordination of refills
- Patient education materials and therapy starter kits from drug manufacturers
- 24-hour hotline staffed by nurses and/or pharmacists to call with medication and injection questions
- Compliance with nationally recognized guidelines and standards
Providers should only bill for the administration of the specialty and complex care medication(s) when received from the preferred pharmacies. Providers may not bill for the specialty and complex care medication.
*The relationship between Blue Cross and Blue Shield of Illinois and the pharmacies is that of independent contractors.
**eRx to NCPDP ID 4436920, 1640 Century Center Parkway, Memphis, TN 38134
Prime Therapeutics LLC is an independent company contracted by Blue Cross and Blue Shield of Illinois to provide pharmacy solutions. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.
Accredo is a specialty pharmacy that is contracted to provide services to members of BCBSIL. The relationship between Accredo and BCBSIL is that of independent contractors. Accredo is a trademark of Express Scripts Strategic Development, Inc.
The listing of any particular drug or classification of drugs is not a guarantee of benefits. The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.