Specialty Rx

Office-administered therapies, sometimes called medical specialty drugs or medical injectables, are specialty medicines that are injected or infused by a health care professional in a doctor’s office. These are not medicines that you pick up from a pharmacy yourself with a prescription.

Your doctor will contact Magellan Rx Management to request a medication review to ensure it is medically necessary and approved for coverage; your doctor will supply any required clinical documentation that supports your need for the medicine. Magellan Rx Management makes a coverage determination based on the information received from your doctor.

Your doctor is then responsible for ordering the specialty medicines from a contracted specialty pharmacy so that it can be administered to you during your office visit.

Self-administered therapies are specialty medicines that are taken orally or self-injected. These are covered through your pharmacy benefit. Your doctor will request a prior authorization from Prime Therapeutics LLC (Prime) to determine medical necessity and coverage of the medicine. Your doctor will also provide a prescription to a participating specialty pharmacy. If the medicine is deemed medically necessary and approved for coverage by Prime, the specialty pharmacy will send/mail the medicine to you. To pay less out-of-pocket for the medicine, it’s important that you use a participating specialty pharmacy. The list of participating specialty pharmacies is below.

Some self-funded and national employer groups have chosen to allow Accredo to exclusively dispense specialty pharmaceuticals on an in-network basis. Refer to your policy documents or call Pharmacy Member Services at the phone number on the back of your Horizon member ID card if you have any questions.

All of the participating specialty pharmacies listed below specialize in these therapies. In addition to a high level of service, drug-/disease-specific education and support from the specialty pharmacy, you get:

• Personal attention from a pharmacist-led team to provide condition-specific education, instructions on how to take the medicine and advice to help manage your therapy.
• Help submitting claims, determine individual coverage and file the necessary paperwork.
• Easy access to pharmacists and other health experts 24 hours a day, seven days a week.
• Informative, condition-specific materials.
• Easy ordering with a dedicated toll-free number.
• Convenient delivery to the location of your choice (your home, doctor’s office, vacation spot, etc.).
• Helpful follow-up care calls to remind you when it’s time to refill a prescription, to check on therapy progress and to answer any questions you may have.

Participating Specialty Pharmacies

Please note:

• Prescription drugs not on the Specialty Pharmaceutical List should still be filled at participating retail or mail-service pharmacies under your prescription drug plan to obtain in-network benefits.
• Specialty pharmaceuticals may be subject to medical necessity review.
• The list of specialty pharmaceutical drugs may be subject to change and updated periodically.

Keep in mind that not all plans cover infertility benefits and related medicines. Refer to your policy documents or call Pharmacy Member Services at the number on the back of your Horizon member ID card for coverage information.