Specialty Pharmacy Program
This program helps deliver specialty medications directly to providers to treat patients’ complex medical conditions, including but not limited to, immune deficiency, multiple sclerosis and rheumatoid arthritis. Due to unique storage and shipment requirements, some specialty medications may not be readily available at local pharmacies.
Specialty medication coverage is based on the member's benefit. Prior Authorization or Predetermination approval may still apply to specific specialty medications. In accordance with their benefits, some members may be required to use a specific preferred specialty 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 Medications
Specialty medications that are U.S. Food and Drug Administration (FDA) approved for self-administration are typically covered under the member’s pharmacy benefit. Some members’ plans may require them to obtain these medications from a specific preferred specialty pharmacy* for benefit consideration.
Blue Cross and Blue Shield of Illinois (BCBSIL) contracts with AllianceRx Walgreens Prime to obtain specialty medications approved for self-administration. To contact AllianceRx Walgreens Prime, call 877-627-6337, e-prescribe the prescription or fax the referral form to the specialty pharmacy location closest to your patient. Note: Some restrictions may apply.
BCBSIL also contracts with select specialty pharmacies to obtain certain self-administered specialty medications for our members.
Physician-Administered Specialty Medications
BCBSIL contracts with select specialty pharmacies to obtain specialty medications for physician administration to our members. These specialty medications are typically covered under the member’s medical benefit.
By obtaining these specialty medications from these preferred specialty 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 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 medication(s) when received from the preferred specialty pharmacies. Providers may not bill for the specialty medication.
HMO Illinois® In-Network Specialty Pharmacies
HMO Illinois and Blue Advantage HMOSM members with prescription drug benefits administered through Prime Therapeutics must fill their specialty medication prescriptions at a pharmacy within the specialty pharmacy network for pharmacy benefit coverage consideration.
*The relationship between Blue Cross and Blue Shield of Illinois and the specialty pharmacies is that of independent contractors.
Blue Cross and Blue Shield of Illinois (BCBSIL) contracts with Prime Therapeutics, a separate company, to provide pharmacy benefit management and other related services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.
Prime Therapeutics has an ownership interest in AllianceRx Walgreens Prime, a central specialty and home delivery pharmacy.
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.