Specialty Pharmacy Program
This program helps deliver specialty medications directly to physicians or to members that include injectable and infused therapies used to treat complex medical conditions such as growth hormone deficiency, hepatitis C, immune deficiency, hemophilia, multiple sclerosis and rheumatoid arthritis. Due to special storage requirements and high cost, injectable specialty medications may not be readily available at local pharmacies.
Blue Cross and Blue Shield of Montana (BCBSMT) contracts with the select specialty pharmacies listed below to ensure availability of specialty medications for our members.* The benefits of obtaining self-injectable specialty medications from these preferred specialty pharmacies include:
- Integrated coordination of coverage between the member, physician and BCBSMT
- No up-front acquisition cost to physicians for non-self-administered/office-based specialty medications
- Convenient delivery of medication to physician's office or member's address
- Injection supplies with every shipment, including alcohol swabs, needles and syringes
- Automatic coordination of refills
- Patient education materials and therapy starter kits from drug manufacturers
- 24-hour hotline staffed nurse and/or pharmacist to call with medication and injection questions
Accredo Health Group, Inc. (Accredo®)
Accredo is a preferred vendor for hemophilia (factor) products. To contact Accredo regarding hemophilia (factor) products, call 866-712-5007. Referral information may be faxed to Accredo at 800-330-0756.
Prime Specialty Pharmacy
Prime Specialty Pharmacy is both a medical and pharmacy provider for a wide variety of specialty medications, including Synagis and hemophilia (factor) medications.
For the current list of managed specialty medications available through Prime Specialty Pharmacy, view the Specialty Pharmacy Program Drug List .
Prime Specialty Pharmacy Referral Forms
To contact Prime Specialty Pharmacy, call 877-627-MEDS (6337) or fax the Prime Specialty Pharmacy injectable request order form to 877-828-3939.
For medications that are FDA approved for self-administration, BCBSMT members with Prime Therapeutics, LLC, as their drug vendor, are required to use their pharmacy benefit and acquire self-administered drugs (oral, topical and injectable) through Prime Specialty Pharmacy. Self-administered drugs must be billed under the member's pharmacy benefit for members to receive coverage.
If services are submitted on professional/ancillary electronic or paper (CMS-1500) claims for drugs that are FDA approved for self-administration and covered under the prescription drug benefit, BCBSMT will notify the provider that these claims need to be re-filed through the member's pharmacy benefit. In this situation, the following message will be returned on the electronic payment summary or provider claim summary: "Self-administered drugs submitted by a medical professional provider are not within the member's medical benefits. These charges must be billed and submitted by a pharmacy provider."
To help you determine the correct path for medication fulfillment and ensure that the correct benefit is applied, please refer to the specialty drug list above. The list identifies those drugs that are approved for self-administration and therefore covered under the pharmacy benefit.
Note: Injectable coverage is based on the member's benefit. Prior Authorization or Predetermination approval still applies to specific medications that fall under clinical review. In accordance with their benefits, some members may be required to use a specific preferred specialty pharmacy. Please call the number on the member's ID card to verify coverage, or for further assistance or clarification on the member's benefits.
Prime Therapeutics Specialty Pharmacy LLC (Prime Specialty Pharmacy) is a wholly owned subsidiary of Prime Therapeutics LLC (Prime), a pharmacy benefit management company. Blue Cross and Blue Shield of Montana (BCBSMT) contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSMT, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime.