Specialty drugs

Specialty medications are the result of continued advances in drug development technology and design. They are created to assist patients suffering from complex disorders, chronic and/or genetic conditions which require specialized therapies and personalized care. These advanced medications target and treat medical conditions and include bioengineered proteins, blood-driven products and complex molecules.

Specialty medications require the prescription be filled at an in-network specialty pharmacy as these medications:

• Can require additional extensive education of the member for safe and cost-effective use
• Can require close monitoring of the patient’s clinical response in collaboration with their provider
• May require member-specific dosing, medical devices to administer the medicine, and/or special handling or delivery
• Can require prior approval before the medication is covered

The Specialty Drug Program addresses treatment for many complex diseases, including:

• Acromegaly
• Anemia
• Cryopyrin-Associated Periodic Syndrome (CAPS)
• Cushing’s Syndrome
• Cystic Fibrosis
• Electrolyte Disorders
• Hemophilia
• Hepatitis
• Hereditary Angioedema
• Idiopathic Pulmonary Fibrosis
• Idiopathic Thrombocytopenic Purpura
• Immunologic Disorders
• Infectious Diseases
• Inflammatory Bowel Disorder
• Iron Overload
• Lipid Disorders
• Movement Disorders
• Multiple Sclerosis
• Neutropenia
• Oncology
• Osteoporosis
• PKU
• Psoriasis
• Pulmonary Arterial Hypertension
• Rheumatoid Arthritis
• Seizure Disorders
• Urea Cycle Disorders

Specialty medications can be found in the Specialty Guideline Management section of the Prior Authorization List and are classified as specialty by the notation of SGM on the Standard and Standard with Step Therapy Formularies. The Metallic Drug List specialty medications are indicated by placement on tier 5 or tier 6. For more information on prior approval requirements and network specialty pharmacies, contact 877-433-2973.