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Anthem Blue Cross : Anthem Blue Cross Specialty Pharmacy Program

Anthem Blue Cross Specialty Pharmacy Program

PW_E169309

A convenient, economical source for biopharmaceutical and injectable medications  
Prescription medications are becoming increasingly more expensive and in greater demand by doctors and patients. New developments in medication therapy have resulted in break-through treatments for complex diseases. These advances have created a relatively new class of prescription medications that is commonly referred to as biopharmaceuticals - also known as specialty medications or specialty drugs.  
Specialty medications are complex in both design and administration. They are used to treat conditions such as multiple sclerosis, cancer, HIV, and certain forms of rheumatoid arthritis. These medications can cost as much as $200,000 per year and are costly to ship, store, and administer.  
Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company may designate or classify certain drugs to be specialty drugs. Herein, the terms specialty pharmaceuticals, specialty prescriptions, specialty drugs, and specialty medications are synonymous and have the same meaning.  
Prescription Drug Benefit Changes
Home Infusion Therapy (HIT) Network Changes
Medical Benefit Changes
Pre-Service Medical Review for Specialty Drugs
Disclaimers
Useful Links
 
Collaboration to improve outcomes  
The Specialty Pharmacy Program is administered by CuraScript, Anthem Blue Cross’ preferred specialty pharmacy. CuraScript is a full-service specialty pharmacy created to more effectively manage and monitor the distribution of specialty drugs. It offers a complete support program including a team of nurses, pharmacists, and pharmacy care advocates who work closely with the prescribing doctor to help members taking specialty medications achieve the best possible outcomes from their treatments. CuraScript can be reached at 1-800-870-6419.  
Through the Specialty Pharmacy Program, members can take advantage of the following benefits:  
Prompt and convenient delivery of the specialty medications and supplies directly to the member’s home, doctor’s office, or other designated location. 
Access to and support from a care management team that can provide helpful information about the specialty medications and pharmacy services.
Dedicated customer service specialists are available to speak with members and providers.
Highly trained, licensed pharmacists and pharmacy technicians prepare every order, with a minimum of three pharmacist quality checks prior to shipping.
Medications are shipped in temperature-controlled packages to help protect the quality of the specialty drugs.
Reminders when it is time to refill the specialty medications, if appropriate.
Patient education, such as a drug’s side effects and how to manage the side effects.
Proactive calls to help manage compliance.
 
Ordering specialty medications through the Specialty Pharmacy Program is designed to be quick, easy and convenient. One simple phone call will get you started.  
CuraScript can be reached at the numbers listed below. Care advocates are available to take calls Monday through Friday, from 5 a.m. to 7 p.m. Pacific Time. After hour calls will be routed to the appropriate on-call staff.  
Phone: 1-800-870-6419
Fax: 1-800-824-2642
Client Advocacy Phone: 1-888-662-0944 (dedicated unit for provider inquiries)
For speech and hearing impaired assistance (TDD/TTY): 1-800-221-6915
For the High Touch Team: 1-866-468-5787
 
Please note that specialty medications cannot be picked up at Anthem Blue Cross, Anthem Blue Cross Life Health Insurance Company, or CuraScript. Specialty medications will be delivered to member’s home, doctor’s office, or other location as designated by the member or doctor.  
Prescription Drug Benefit Changes  
The prescription (or pharmacy) drug benefits for medications categorized as specialty drugs may have changed for Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company members. This change requires that members obtain specialty drugs through the Specialty Pharmacy Program, administered by CuraScript.  
Depending on the Evidence of Coverage or Certificate, specialty medications may not be covered if they are obtained from another pharmacy other than CuraScript. To give the members and their doctors enough time to contact CuraScript to set up the specialty prescriptions, the plan allows for the members to get the first two (2) fills of the specialty medication(s) at a participating retail pharmacy.  
Members will be notified by a letter when they get a specialty medication filled at a participating retail pharmacy the first two (2) times. After which, the members may be responsible for the entire cost of the specialty medication(s) if they continue to use a pharmacy other than CuraScript. Under certain urgent medical situations, an exception may be requested to allow the member to use another pharmacy. Unless the exception is approved, the member may be responsible for the total cost of the specialty medication(s).  
Specialty medication(s) may also be limited to a 30-day supply for each fill. The standard retail copay or coinsurance may apply to each 30-day supply. Please check the EOC or Certificate for more information.  
Please note that Prior Authorization of Benefits (PAB) requirements still apply to specialty drugs covered under the prescription drug benefit. The prescribing doctor will need to fax the request to our prescription drug plan. Please refer to the Pharmacy Programs link for more information and PAB forms.  
Click here for the Specialty Drug list  
Click here for a Pharmacy Exception Request Form  
 
Home Infusion Therapy (HIT) Network Changes  
Effective 9/1/2007, Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company made some changes to our Home Infusion Therapy (HIT) provider network. A Home Infusion Therapy provider generally provides drugs, supplies, and equipment to be used in the member’s home for the infusion of medications such as antibiotics, chemotherapy, total parental nutrition (TPN), and pain management. Some HIT providers may also have locations where members receive their infusion(s). These therapies are generally covered under the member’s medical benefits and not pharmacy or prescription drug benefits. The changes made were:  
1. For certain specialty medications, the member or HIT provider must obtain them from CuraScript. Members may be responsible for the total cost of the specialty medication(s) if they are obtained from another source other than CuraScript. Similarly, if a HIT provider does not get these specialty medications from CuraScript, they may be not be reimbursed for them  
2. For specialty medications called intravenous immune globulins (IVIG) or subcutaneous immune globulin (Vivaglobin), members and providers must order these through Crescent Healthcare Inc., our preferred HIT provider for IVIG and Vivaglobin. Crescent can be reached at 1-877-872-4844.  
3. For urgent circumstances, the HIT provider can obtain authorization from Blue Cross to provide the specialty medication to our members without having to use CuraScript.  
Click here for a list of the Medical Benefit Specialty Drugs  
For a listing of the HIT providers in our network, please use the provider finder tool, select Provider Type as Other Providers, then Provider Specialty as Home Infusion Therapy Provider or call the customer service number on the back of the member’s identification card.  
Medical Benefit Changes  
Similar to the pharmacy benefit changes described above, medications that are designated as “specialty drugsand may be covered under the members’ medical benefits must be obtained through CuraScript. This applies to specialty drugs that are obtained for home use or to be administered in the physician office during the office visit.  
Depending on the Evidence of Coverage (EOC) or Certificate, specialty medication(s) may not be covered if they are obtained from another source other than CuraScript. Specialty medications may be limited to a maximum of a 30-day supply per order or the treatment needed during the office visit, whichever is less. If the doctor orders the specialty drug to be administered in the office, only the medication needed for that visit will be delivered. The specialty pharmacy can deliver specialty medication(s) to member’s home or physician’s office by mail or common carrier (the specialty medications cannot be picked up at Anthem Blue Cross or Anthem Blue Cross Life and Health Insurance Company).  
To give members and physicians enough time to contact CuraScript to set up the order(s), the plan allows for the first two (2) orders of specialty medication(s) to be obtained from another source. After that, the members may be responsible for total cost of the specialty medication(s). Under certain urgent medical situations, an exception may be requested to allow the member to use another source. Please check the EOC or Certificate for more information.
Please note that for Hemophilia members receiving care and treatment from a provider that participates in the 340B program, they do not have to use the specialty pharmacy program. Members can continue to receive their specialty medications, called factors, from these providers.
 
Click here for a list of the Medical Benefit Specialty Drugs  
Click here for a Medical Exception Request Form  
 
Pre-Service Medical Review for Specialty Drugs  
A number of specialty medications that may be covered under the medical benefit may require utilization management (UM) review. UM review is performed by our Specialty Pharmacy Medical Management (SPMM) unit. SPMM is different from the pharmacy PAB program above, which is managed by Anthem Blue Cross’ prescription drug plan. This requirement applies primarily to Anthem Blue Cross and Anthem Blue Cross Life and Health PPO members. Generally, for HMO members, the assigned Primary Medical Group performs the utilization management review. For detailed information please click here  
Click here for a list of SPMM Prior Authorization Specialty Drugs  
Disclaimers  
The specialty drug lists herein are subject to change. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company may designate certain drugs to be specialty drugs, if they meet the criteria.  
The listing of specialty drugs or medications is not a guarantee of coverage; please refer to the Evidence of Coverage (EOC) or Certificate for specific coverage information, benefit limitations, and restrictions.  
Non-duplication of benefits applies to the specialty pharmacy program. When benefits are provided for specialty drugs under the plan’s medical benefits, they will not be provided under the PRESCRIPTION DRUG BENEFITS, if included. Conversely, if benefits are provided for specialty drugs under the PRESCRIPTION DRUG BENEFITS, if included, they will not be provided under the plan’s medical benefits.  
Useful Links  
List of Pharmacy Benefit Specialty Drugs
List of Medical Benefit Specialty Drugs
Anthem Blue Cross Pre-Service Medical Review for Specialty Drugs
Anthem Blue Cross Preferred Specialty Pharmacy – CuraScript
 

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.