Specialty Medications for Active Employees Enhanced PPO Plan (80/20)

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 special 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 a complex medical condition
• 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 requirements

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. The formulary or drug list is regularly updated throughout the year, on a quarterly basis, so there is always a possibility that the coverage status of your medication(s) could change, which may affect your out-of-pocket costs.

• 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 888-321-3124 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 888-321-3124 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 888-321-3124 . 
  • 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 888-321-3124 or visit Caremark.com.