Specialty Drugs

Vials and pills
All of our pharmacy benefits plans may include a Specialty Pharmacy Benefit. To determine if your plan includes this coverage, please call your account executive.

Specialty drugs are high-cost injectable, infused, oral, or inhaled medications that are typically prescribed to treat chronic or long-term conditions that have few or no alternative therapies, such as cancer, HIV/AIDS, hepatitis C, multiple sclerosis, and others. People who take specialty drugs require customized clinical monitoring and support to reduce their health risks and potentially serious side effects.

Network Specialty Pharmacies
Blue Cross has designated two pharmacies within our network to provide specialty drugs to our members who need them, at the most reasonable cost possible:

  • Walgreens Specialty Pharmacy 1-877-646-4292
  • Village Fertility Pharmacy (fertility drugs only): 1-877-334-1610

If you have any questions about our Specialty Pharmacy Benefit, please contact your account executive.

How the Specialty Pharmacy Benefit Works

  • All drugs listed on the Specialty Drug List must be obtained from a preferred specialty pharmacy in order to receive the maximum benefit.
  • The Specialty Drug List includes selected drugs that were previously covered under the medical benefit. These selected drugs are no longer eligible for medical benefit coverage and are covered under the Specialty Pharmacy Benefit.
  • The highest network prescription drug copayment applies to specialty drugs (other than infertility drugs) that are purchased from one of our network specialty pharmacies.
  • A 20 percent copayment applies to specialty drugs that are used for infertility treatment.
  • Specialty drugs purchased from nonparticipating specialty pharmacies or retail pharmacies will have a higher out-of-pocket cost.
  • Certain specialty drugs require prior authorization.
  • Specialty drugs cannot be purchased through CVS Caremark Mail Service Pharmacy, our mail order service.

The level of coverage depends on where the specialty drugs are obtained:

  • If purchased at a pharmacy: For the maximum benefit, specialty drugs should be purchased from one of the two network specialty pharmacies listed above. Specialty drugs purchased from nonparticipating specialty pharmacies or retail pharmacies must be paid in full by the member at the time of purchase. The member is then required to submit the receipt(s) to Blue Cross for reimbursement of 50 percent of our allowance. Members must obtain prior authorization from their doctor(s). Please note that specialty drugs are not available through CVS Caremark Mail Service Pharmacy.
  • If administered at a physician’s office or by a home infusion provider within the Blue Cross network: When specialty drugs are administered by a physician or by a home infusion provider who participates directly with Blue Cross, they must be purchased at a participating specialty pharmacy. The physician is responsible for obtaining any prior authorizations. The provider prescribes and orders the specialty drugs at a participating specialty pharmacy, and members are responsible for paying the copayment to that pharmacy.
  • If administered at a physician’s office or by a home infusion provider outside the Blue Cross network: To get the maximum benefit when specialty drugs are administered by nonparticipating providers (including providers who participate with another Blue Cross and Blue Shield plan through the BlueCard Network), members must ensure that:

Otherwise, members may be responsible for up to the full cost of the medication. Please refer to the subscriber agreement to determine eligibility for specialty drug coverage under the pharmacy benefit.

If you have any questions about specialty drug coverage, please read these FAQs or contact Customer Service at (401) 459-5000 or 1-800-639-2227 (outside of Rhode Island).