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Cut the confusion on specialty drugs

What you need to know

If you or a loved one has been diagnosed with a serious health condition, you’ve most likely heard about specialty drugs Opens New Window.

Specialty drugs are used to treat complex and chronic illnesses. These drugs require special handling, injection or further supervision. While specialty drugs are essential to treating autoimmune disorders, cancer and other chronic conditions, there is no denying the layer of confusion they can add.

Find the answers you need about specialty drugs to maximize your prescription drug benefits.

Why are specialty drugs so expensive?

Specialty drugs are expensive

Because specialty drugs are often used to treat rare or costly conditions, they typically come with a hefty price tag. While drug manufacturers control the true price of specialty drugs, Wellmark Blue Cross and Blue Shield's pharmacy benefit manager (PBM) negotiates with the manufacturers to bring the price down. Depending on your plan benefits, you may have a copay for the drug. A copay is a fixed amount that you may have to pay out-of-pocket when filling a prescription at the pharmacy. Alternatively, you may have to pay a fixed percentage of the drug price. Let your pharmacist know if you are having difficulty affording the cost of your specialty medication. There may be a copay card available that can help offset your cost.

Want to cut your specialty drug costs?

You may be paying more than you should for a specialty drug. Specialty drugs can be considered preferred or non-preferred. Preferred specialty drugs are safer, more effective and more cost-efficient than non-preferred specialty drugs. If you are currently taking a non-preferred specialty drug, you should ask your pharmacist if there is a lower cost alternative. To identify your drug's classification, find lower-cost alternatives or see the cost of drugs before you head to the pharmacy, register or log in to myWellmark® Opens New Window.

Is my specialty drug covered under my medical or prescription drug plan?

If you are trying to meet your out-of-pocket maximum or deductible, it’s important to know how your out-of-pocket drug expenses accumulate. There are two ways a specialty drug may be covered under your plan, and it largely depends on where you receive the drug.

  • Medically benefited drug: Typically, if you receive a specialty drug in your doctor’s office or in an outpatient setting, it is covered under your medical benefits and considered a medically benefited drug.
  • Pharmacy-benefited drug: If you purchase the drug at your pharmacy or are taking the drug yourself, then it is most likely covered through your pharmacy benefits. These drugs are considered pharmacy-benefited drugs.

It’s important to know if your drug is covered under your medical or pharmacy benefits because it can change how much you will pay out-of-pocket. You can see how your out-of-pocket costs accumulate and more by logging in to myWellmark.

Do I need to fill my specialty medications at a certain pharmacy?

Most health insurers have preferred pharmacies to better control the cost of drugs. With Wellmark, you are typically required to refill your specialty medications through one of our preferred vendors, CVS SpecialtyTM External Site or Hy-Vee Pharmacy Solutions External Site1.

Wellmark has agreements with these pharmacies so they cannot charge our members more than their benefits allow. They both also offer mail-order deliveries Opens New Window for certain medications if that option works better for you. To find out if you must use CVS Specialty or Hy-Vee for your specialty pharmacy prescriptions, log in to myWellmark.

myWellmark and your pharmacy benefits

Register or log in to myWellmark Opens New Window to better understand your prescription drug benefits and take control of your health care. The prescription drug tools on myWellmark can help you locate your local in-network pharmacy, sign up for mail-order delivery and even track your specialty drug prescriptions.

1Specialty drug coverage varies by plan. Please check your coverage manual to know which preferred pharmacy is covered by your plan.