Information:

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Specialty drug program

What’s a specialty drug?

Specialty drugs are prescribed medicines that treat rare, chronic or complex conditions, such as:

Specialty medicines are usually taken by mouth or injected. These drugs typically require a higher degree of management from your care team, and they can also come at a higher price. Specialty drugs usually aren’t carried by retail pharmacies. Instead, they’re often carried by specialty pharmacies or administered in health care settings.
  • If you have a Medicare plan with us – See our Medicare Part D formulary page for more details about specialty drugs.
  • If you have any other plan with us – You can find details about our specialty drug program below.

Identifying specialty drugs

You can find out which drugs are considered specialty medicines by searching your plan’s formulary (drug list). Specialty medicines are indicated directly below the drug’s name.

Please note that some specialty medicines are covered under your pharmacy benefits, while others are covered under your medical benefits. For more details about your plan’s pharmacy and medical benefits, you can sign in to review your coverage online.

If you’re not sure if a drug is a specialty medicine (or how it’s covered), contact Member Services for help.

Coverage criteria and prior authorization for specialty medicines

Most specialty medicines require prior authorization before your plan will pay for them.

To find out if a specialty medicine you’ve been prescribed requires prior authorization:

  1. First, search your plan’s formulary – Specialty medicines with the “Prior Authorization Required” indicator require HealthPartners approval before they can be covered.
  2. Then, search our medical coverage criteria – Some medical-covered drugs require prior authorization, but this requirement isn’t noted in your formulary. However, it is noted in our medical coverage criteria.

If you have questions about your specific situation or need help, contact Member Services.

How does the specialty drug program work? What’s a specialty pharmacy?

We partner with specialty pharmacies that safely fill and conveniently deliver your medicines. In addition, specialty pharmacies provide:

  • No-cost shipping and handling
  • Monthly reorder reminders
  • Acceptance of manufacturer coupons

A manufacturer coupon is a coupon issued by a drug company to help you save money on a particular medicine, with the manufacturer absorbing part of the cost. These work with most group and individual and family plans that have prescription drug coverage. They don’t work with Medicare and Medical Assistance (Medicaid) plans.

If you present a manufacturer coupon to your pharmacy, your out-of-pocket cost will typically be the lower of the amount stated on the coupon or your plan’s regular cost-sharing amount for the drug. Amounts paid by manufacturers may not apply to any deductibles or out-of-pocket limits your plan may have.

Not sure if there’s a manufacturer coupon available for your medicine? Ask the pharmacist at your specialty pharmacy. They may be able to see if there’s a coupon available and, if so, help you use it toward your medicine.

HealthPartners plan network specialty pharmacies

This list applies to specialty medicines covered under your pharmacy benefits. (Specialty medicines covered under your medical benefits are typically administered in health care settings.)

Important things to keep in mind

  • This list doesn’t apply to employer groups that have unique specialty network requirements. For these groups, you can find your network list among your plan’s documents and resources. If you’re not sure if your employer has a separate specialty pharmacy network, our Member Services team can help.
  • In limited instances, CVS Caremark Specialty Pharmacy will have to supply a specialty medicine regardless of the condition being treated. This is due to manufacturer limitations.

Need help?

For questions about your specialty medicine, contact your specialty pharmacy directly.

For questions about your plan’s coverage of specialty medicine, our Member Services team can help.