Specialty pharmacy

Specialty pharmacy is a continued area of focus at HealthPartners as the industry continues to see significant cost increases for specialty medications. Although only a small number of prescriptions drive that cost, specialty medications are the fastest growing segment of the pharmaceutical industry.

Coverage

All drugs are reviewed by the HealthPartners Pharmacy and Therapeutics (P&T) Committee. This committee promotes the appropriate use of high quality and cost-effective pharmaceuticals for HealthPartners members. Self-administered medications are reviewed for formulary status and all medications are reviewed for coverage criteria. Prior to P&T review and coverage determination, all drugs require review for medical necessity and approval to ensure payment.

Self-administered drugs

To reduce costs and ensure knowledgeable pharmacy care for these conditions,we have made exclusive arrangements with specialty pharmacy providers for self-administered specialty medications.

Beginning 1/1/2013,CVSCaremark Specialty Pharmacy is responsible for providing the majority of specialty medications. Other pharmacies provide specialty medications when there is additional clinical support or cost benefits. Self-administered specialty medications may be dispensed by the following pharmacies:

CVSCaremark Specialty Pharmacy Most Specialty Drugs
Walgreens Specialty Pharmacy Infertility Products
CVS CareMark Specialty Pharmacy Growth Hormones
Fairview Specialty Pharmacy Blood Factors, Cystic Fibrosis Products
Childrens Hospitals & Clinics Pharmacy Blood Factors, Cystic Fibrosis Products

Members have the convenience of having these medications delivered directly to their homes for no additional charge, working with pharmacy teams familiar with these conditions including access to a pharmacist 24 hours per day and monthly refill calls to ensure adherence to the care plan from their provider team.

Local retail pharmacies (e.g.CVS, Walgreens, Target,etc.) are not able to process these prescriptions for health plan coverage. CVS Caremark does offer delivery to a CVS retail store, but members must make arrangements through CVS Caremark Specialty Pharmacy.

Ordering drugs from the specialty pharmacy

The process may be started by either members or providers. Providers may send referrals or prescriptions directly to the specialty pharmacy or to the manufacturers HUB or call center. Once the form is received, the member will be contacted to arrange for the delivery of the medication. All specialty medications and supplies are delivered directly to the home or preferred address.

CVS Caremark Specialty Pharmacy has disease-specific ordering forms available for use. Click here to access forms.

This program applies only to specialty medications and members can continue to obtain all other non-specialty prescription medications through our retail pharmacy network or HealthPartners mail order pharmacy.

Professionally administered drugs

This program doesnt apply to drugs administered by professionals in the home or clinic setting. Self-administered injectable drugs included in the specialty drug lists are generally not eligible for reimbursement through a medical claim. When in-clinic administration is medically necessary, the drug should be sourced through our specialty pharmacy providers and sent to the clinic for administration. Administration costs are eligible for reimbursement through a medical claim.

Review the Specialty drug list, Growth hormone list and Infertility list .