Specialty drugs are prescription medications that require special handling, administration, or monitoring. These drugs are used to treat complex, chronic and usually costly conditions. Specialty drug are expensive, and there are usually no generic substitutes. At FlexScripts, specialty drugs are our specialty. Here are some examples of how we can help you navigate this confusing and expensive landscape.
Prior Authorization Requirements
All Specialty medications have very specific prior authorization (PA) criteria that must be met before a Plan will pay for the medicine. Also, any claim over $750 also requires a PA.
Day Supply Limits
Patients can receive no more than a 30-day supply of any Specialty medication, based on defined dosing criteria and Food and Drug Administration (FDA) Guidelines.
Compliance Mechanisms
After a thorough review and approval by our clinical staff, a patient will be authorized to receive a Specialty medication one month at a time for the first three months. We do this to establish the compliance with both the prescriber and the member. This built-in process allows early and better oversight to ensure a successful outcome.
Dispensing Restrictions
Specialty medications are only dispensed at specific specialty pharmacies.
Intensive Case Management
All prior authorizations are reviewed by our clinical staff on an individual basis. Example criteria include:
- Plan’s pharmacy benefit covers medication. Exceptions might include fertility medications or non-self-administered medications.
- Diagnosis provided matches a FDA-approved indication and appropriate age.
- Dosing of medication aligns with FDA-approved indication.
- Appropriate Step Therapy. For example, Humira® is often prescribed for psoriasis. However, a member must have had an inadequate response to one of two oral medications (methotrexate or cyclosporine) before they can be approved to use it.