Fee-for-Service Specialty Pharmacy Drug Program
The Department of Human Services ("the Department") is contracted with two nationally recognized specialty pharmacies to serve as the preferred specialty pharmacy providers for Medical Assistance (MA) beneficiaries who receive pharmacy benefits under the Fee-for-Service delivery system (i.e., ACCESS). Fee-for-Service beneficiaries must obtain drugs included in the Specialty Pharmacy Drug Program from one of the Department's preferred specialty pharmacy providers.
Please refer to the list of drugs included in the FFS Specialty Pharmacy Drug Program.** This list will be updated periodically.
** Pennsylvania Fee-for-Service (FFS) has been informed of a temporary manufacturer backorder affecting the availability of all adult strengths of Lupron (Depot) injections. In response, effective September 9, 2020, PA FFS will temporarily suspend the specialty restriction on the adult strengths of Lupron until this shortage has been resolved. At this time, any enrolled pharmacy or dispensing provider may bill for Lupron.
- Who is impacted by the Specialty Pharmacy Drug Program?
- Specialty Pharmacy Drug Program Preferred Specialty Pharmacy Providers
- What are specialty drugs?
- What services to the preferred specialty pharmacy providers offer to MA beneficiaries?
- How will I get my specialty drug?
- Additional Information for Prescribers - Dispensing and Delivery Services for Specialty Drugs
Who is impacted by the Specialty Pharmacy Drug Program?
The program applies to MA beneficiaries whose pharmacy services are covered under the FFS delivery system and who use the FFS ACCESS card for their pharmacy services.
The program does not apply to MA beneficiaries who are enrolled in a Medicaid managed care organization (MCO) or whose specialty medications are covered by Medicare Part B, Medicare Part D, or a private health insurance plan unless those plans do not cover the specialty drug and the drug is covered by the FFS program.
Specialty Pharmacy Drug Program Preferred Specialty Pharmacy Providers
UPDATE 10/1/2020: 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.
What are Specialty Drugs?
Examples of specialty drugs include medications that:
- Are used to treat chronic and/or life-threatening diseases.
- Are expensive.
- Require training for administering the drug.
- Require additional monitoring or counseling.
- Require temperature control or other specialized handling.
Specialty drugs may be subject to the Statewide Preferred Drug List, requirements for prior authorization, and quantity limits/daily dose limits.
What services do the preferred specialty pharmacy providers offer to MA beneficiaries?
The preferred specialty pharmacy providers will:
- Contact you to ask you some questions to learn more about you and to plan for support services that you may need while taking the specialty drug.
- Contact you about 10 days prior to your refill date to see if there have been any changes in your therapy and set up a date for delivery.
- Deliver your specialty drug. This may be to the doctor's office, a clinic, a treatment center, or your home or other designated location.
- Teach you or your caregiver how to use your specialty drug.
- Coordinate with home nursing services if your doctor determines that the specialty drug must be administered by a nurse.
- Provide training and information about your specialty drug including how to properly handle and store your drug, possible side effects, and how to manage side effects, etc.
- Provide a toll-free phone number for the patient call center run by the preferred specialty pharmacy provider that is available 24 hours a day, 7 days a week to answer any medical questions you may have about your specialty drug.
- Monitor for drug interactions or any issues you may experience with your specialty drug.
Additional benefits include:
- No co-payments for specialty drugs.
- Free shipping.
- Free administration supplies.
- You can continue to get all non-specialty drugs at the pharmacy you usually use.
How will I get my specialty drug?
- Talk with your doctor to decide which specialty pharmacy provider to use. Your doctor may order your prescription electronically or by phone or fax.
- The specialty pharmacy will call you to arrange for delivery of the specialty drug to the location you and your doctor specify, which could include your doctor's office, a clinic, a treatment center, or your home or work.
- If you are currently getting your specialty drug from a non-preferred pharmacy, you can contact the preferred specialty pharmacy provider directly and ask them to contact your doctor to get a prescription.
- The specialty pharmacy will coordinate nursing services if needed. You can choose to use the specialty pharmacy's nursing services or any MA-enrolled home health provider.
Accessing a Drug Included in the Specialty Pharmacy Drug Program
- 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 before contacting the preferred specialty pharmacy provider. Please refer to the Pharmacy Prior Authorization General Requirements for information about the prior authorization process.
- 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.
- 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.
- The preferred specialty pharmacy provider will contact the MA beneficiary to provide information about the preferred specialty pharmacy provider's patient care coordination services.
- 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.
- The preferred specialty pharmacy provider will coordinate in-home nursing services to administer the specialty medication to the MA beneficiary when necessary.
- 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.
- 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.
- 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.