Specialty Medications
Specialty medications are used to manage long-term (chronic), rare and complex conditions or genetic disorders. These include rheumatoid arthritis, cancer, multiple sclerosis, growth hormone disorders, immune deficiencies, and more. The medications are often injectable or intravenously (IV) infused, but may also be in oral or inhaled form. These medications typically have special storage and handling needs and cost more than other drugs because of the way the drugs are made.
As a part of your pharmacy benefit, specialty medication services are available to you exclusively through the Caremark Specialty Pharmacy. CVS Caremark Specialty Pharmacy is the specialty pharmacy provider for CVS Caremark, providing special support for patients taking specialty medications, including 24-hour access to pharmacy services and emergency pharmacist consultation, as well as ongoing support and counseling.
Additionally, Caremark’s Specialty Connect program offers you flexibility and choice, making it easier and more convenient for you to drop off and pick up your specialty prescriptions either through a CVS/pharmacy or by mail. After you drop off a specialty prescription at a CVS/pharmacy, the prescription is transferred to the Caremark Specialty Pharmacy for filling. The filled prescription is then either sent back to your CVS/pharmacy for pick-up (except in West Virginia, Arkansas and Oklahoma) or mailed directly to you, depending on which method you choose. Learn more about the CVS Caremark Specialty Pharmacy here
For a list of medications that must be dispensed by CVS Caremark Specialty Pharmacy, log onto www.caremark.com or call 1-800-237-2767. Since the list is subject to change, you may wish to call 1-800-237-2767 for the most current list of covered specialty medications dispensed by the CVS Caremark Specialty Pharmacy.
In general, the drugs on this list will not be covered by any pharmacy except for CVS Caremark Specialty Pharmacy regardless of their medical necessity, their approval, or whether you have a prescription written by a physician or other provider. In limited circumstances, however, coverage may be allowed through an alternate provider. Those circumstances include:
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Specialty medications billed by a facility as part of an inpatient hospital stay;
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Specialty medications billed as part of an emergency room visit;
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Situations where Medicare is the primary carrier;
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Limited distribution specialty medications where CVS Caremark does not have access to the drug;
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When homecare is not clinically appropriate (either due to the Member’s clinical history or due to characteristics of the drug which require special handling) and an alternative infusion site (that is qualified to administer the drug) is not available for coordination of services within a reasonable proximity (30 miles or less). The situation will be evaluated by CVS Caremark clinical staff; and
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The treating physician provided written documentation outlining the clinical rationale for the requirement that the Member be treated at the designated facility and confirming that the designated facility is unable to accept drug dispensed by CVS Caremark. The written documentation will be reviewed and approved by appropriate CVS Caremark clinical personnel before allowing coverage for the requesting provider under the medical benefit. The situation will be evaluated by CVS Caremark clinical staff.
Select specialty medications covered only under the pharmacy benefit through CVS Caremark Specialty Pharmacy are excluded from coverage under the medical plan.
Prior authorization may be required for any specialty medication, regardless of whether it is filled through the prescription drug plan or the medical plan.
The Caremark Specialty Pharmacy program not only provides specialty medications, but also provides personalized pharmacy care management services:
- Access to an on-call pharmacist 24 hours a day;
- Convenient, prompt and discreet delivery;
- Disease-specific education and counseling;
- Proactive refill reminder phone calls;
- Benefit verification and reimbursement support;
- Coordination of patient care with physician’s office; and
- Caremark Specialty supports safe, clinically appropriate and cost-effective specialty medications and may make calls to your physician about your therapy. As a result, your physician may decide to make changes in your therapy.
The Caremark Specialty Pharmacy program encourages the use of a drug on the Preferred Drug List prior to the use of medicines that are not on the Preferred Drug List. If you have not tried the drug on the Preferred Drug List, a Prior Authorization must be completed before the non-preferred medicine will be covered. This means that the Caremark Specialty Pharmacist will speak with your physician about the medication choices but only your physician can decide which drug you will receive.
Specialty services are available toll-free at 1-800-237-2767, through CaremarkConnect, Monday through Friday from 6:30 a.m. to 8 p.m. (Central Time). For those plan participants requiring telecommunications device (TDD) assistance, please dial toll-free 1-800-231-4403.
