New Fee-for-Service Specialty Pharmacy Drug Program Preferred Specialty Pharmacy Providers

The Department selected the following nationally accredited specialty pharmacy providers through the competitive bidding process to serve as the Department's preferred providers of medications included in the Specialty Pharmacy Drug Program beginning October 1, 2020:

The Department provided the preferred specialty pharmacy providers with a list of prescribers currently prescribing drugs designated as specialty medications to Medical Assistance (MA) beneficiaries whose pharmacy services are covered under the Fee-for-Service (FFS) program. The specialty pharmacy providers will send a letter of introduction to those prescribers that includes a description of the services provided by the preferred specialty pharmacies and the pharmacy's contact information.

The Department sent client-specific notices to all MA beneficiaries with a recent history of a paid claim for a drug included in the Specialty Pharmacy Drug Program.  The client-specific notice identifies the specialty medication and explains what the MA beneficiary must do to continue to get that drug.  The notice instructs the MA beneficiary to contact their prescriber or the preferred specialty pharmacy provider to ensure that they do not experience any interruption in service.

Accessing a Drug Included in the Specialty Pharmacy Drug Program

1. The prescriber may call, fax, or electronically transmit the prescription for a specialty medication to the MA beneficiary's preferred specialty pharmacy provider listed above. If the MA beneficiary is currently taking a specialty medication that was previously dispensed by another pharmacy, the MA beneficiary can contact the preferred specialty pharmacy provider and ask the specialty pharmacy to contact the prescriber for a new prescription or contact the other pharmacy to obtain a transfer of the current prescription.
   
   If the specialty drug is to be administered in the MA beneficiary's home, the prescriber may also order any ancillary supplies needed for administration and, if necessary, indicate the in-home health provider that the beneficiary prefers to administer the medication.
   
   NOTE: If the specialty medication requires prior authorization, the prescriber must initiate the request for prior authorization with the Department before contacting the preferred specialty pharmacy provider. Please refer to "Prior Authorization for Drugs Included in the Specialty Pharmacy Drug Program" section below.
   
   
2. The prescriber should identify where, when, and how often the specialty medication should be delivered. If the prescriber does not provide this information with the prescription, the preferred specialty pharmacy provider will contact the prescriber to obtain this information.
   
   
3. At initiation of therapy (either a new prescription or the first time using the preferred specialty pharmacy provider), the preferred specialty pharmacy provider will contact the prescriber and/or the MA beneficiary to collect pertinent patient information.
   
   
4. The preferred specialty pharmacy provider will contact the MA beneficiary to provide information about the preferred specialty pharmacy provider's patient care coordination services.
   
   
5. If the prescriber indicated to the preferred specialty pharmacy provider that the specialty medication should be delivered to the MA beneficiary, the preferred specialty pharmacy provider will contact the MA beneficiary to arrange for delivery.
   
   
6. The preferred specialty pharmacy provider will coordinate in-home nursing services to administer the specialty medication to the MA beneficiary when necessary.
   
   
7. The preferred specialty pharmacy provider will mail a packet to the MA beneficiary containing information about the beneficiary's specialty medication, the services offered by the preferred specialty pharmacy provider, and details about how to contact the preferred specialty pharmacy provider.
   
   
8. The preferred specialty pharmacy provider will deliver the specialty medication to the prescriber's office, MA beneficiary's home or work, or other chosen location on the "needs by" date requested by the prescriber.
   
   
9. REFILLS: The preferred specialty pharmacy provider will contact the prescriber and/or the MA beneficiary to confirm that the beneficiary is still receiving therapy with the specialty medication prior to delivering a refill. NOTE: The preferred specialty pharmacy provider will not deliver the specialty medication without this confirmation.

Prior Authorization for Drugs Included in the Specialty Pharmacy Drug Program

If the prescribed specialty medication requires prior authorization, the prescriber must initiate the request for prior authorization before contacting the preferred specialty pharmacy provider.  Providers may refer to the list of drugs included in the Specialty Pharmacy Drug Program to identify specialty drugs that require prior authorization at https://www.dhs.pa.gov/providers/Pharmacy-Services/Pages/Specialty-Pharmacy-Program.aspx    

If a drug included in the Specialty Pharmacy Drug Program requires prior authorization, the prescriber must request prior authorization in accordance with the procedures in SECTION I of the Prior Authorization of Pharmaceutical Services Handbook.  As set forth in 55 Pa. Code § 1101.67(a), the procedures described in the handbook pages must be followed to ensure appropriate and timely processing of prior authorization requests for drugs that require prior authorization.

The FFS pharmacy prior authorization general requirements and procedures are also outlined on the Department's website at https://www.dhs.pa.gov/providers/Pharmacy-Services/Pages/Pharmacy-Prior-Authorization-General-Requirements.aspx.