Specialty drugs are high-cost injectable, infused, oral, or inhaled medications that are typically prescribed to treat chronic or long-term conditions that have few or no alternative therapies, such as cancer, HIV/AIDS, hepatitis C, multiple sclerosis, and others. People who take specialty drugs require customized clinical monitoring and support to reduce their health risks and potentially serious side effects.
Network Specialty Pharmacies Blue Cross & Blue Shield of Rhode Island (BCBSRI) has designated two pharmacies within our network to provide specialty drugs to our members who need them, at the most reasonable cost possible:
For Members Who Have the Specialty Pharmacy Benefit Here’s what providers need to know about the new specialty drug benefit beginning April 1, 2008, or upon their employer’s or group’s renewal of coverage:
All drugs listed on the Specialty Drug List must be obtained from a preferred specialty pharmacy in order to receive the maximum benefit.
The Specialty Drug List includes selected drugs that were previously covered under the medical benefit. These selected drugs are no longer eligible for medical benefit coverage and are covered under the Specialty Pharmacy Benefit.
The highest network prescription drug copayment applies to specialty drugs (other than infertility drugs) that are purchased from one of our network specialty pharmacies.
A 20 percent copayment applies to specialty drugs that are used for infertility treatment.
Specialty drugs purchased from nonparticipating specialty pharmacies or retail pharmacies will have a higher out-of-pocket cost.
Certain specialty drugs require prior authorization.
Specialty drugs cannot be purchased through PrecisionRx, our mail order service.
Providers can verify if a member has the specialty pharmacy benefit by checking member eligibility online. View an example of a specialty pharmacy benefit member's eligibility.
The level of coverage depends on where the specialty drugs are obtained:
If purchased at a pharmacy: For the maximum benefit, specialty drugs should be purchased from one of the two network specialty pharmacies listed above. Specialty drugs purchased from nonparticipating specialty pharmacies or retail pharmacies must be paid in full by the member at the time of purchase. The member is then required to submit the receipt(s) to BCBSRI for reimbursement of 50 percent of our allowance. Members must obtain prior authorization from their doctor(s). Please note that specialty drugs are not available through PrecisionRx.
If administered at a physician’s office or by a home infusion provider within the BCBSRI network: When specialty drugs are administered by a physician or by a home infusion provider who participates directly with BCBSRI, they must be purchased at a participating specialty pharmacy. The physician is responsible for obtaining any prior authorizations. The provider prescribes and orders the specialty drugs at a participating specialty pharmacy, and members are responsible for paying the copayment to that pharmacy.
If administered at a physician’s office or by a home infusion provider outside the BCBSRI network: To get the maximum benefit when specialty drugs are administered by nonparticipating providers (including providers who participate with another Blue Cross and Blue Shield plan through the BlueCard Network), members must ensure that:
The specialty drug is purchased from a network specialty pharmacy, and
Their physician obtains prior authorization, if applicable.
Otherwise, members may be responsible for up to the full cost of the medication. Please refer to the subscriber agreement to determine eligibility for specialty drug coverage under the pharmacy benefit.
If you have any questions about specialty drug coverage, please contact the Physician and Provider Service Center at (401) 274-4848 or 1-800-230-9050.
