Traditional Pharmacy Benefits

Specialty Medications*

*This applies to the Traditional 70/30 Plan, Enhanced 80/20 Plan and Consumer-Directed Health Plan (CDHP).

Many complex conditions are treated with specialty medications. Specialty medications are FDA approved drugs including Biosimilars that are typically injectable medications administered either by you or a health care professional, and they often require special handling. Conditions commonly requiring specialty medications include:

  • Anemia
  • Asthma
  • Growth Hormone Deficiency
  • Hemophilia
  • Hepatitis C
  • Multiple Sclerosis
  • Rheumatoid Arthritis

Medications classified by the State Health Plan as specialty or Biosimilar medications meet all of the following conditions:

  • Have unique uses for the treatment of complex diseases
  • Require special dosing or administration
  • Require special handling
  • Are typically prescribed by a specialist provider
  • Exceed $400 cost to the Plan per prescription

The State Health Plan designates between self-administered specialty medications and provider-administered specialty medications for benefit coverage. Please refer to the Specialty Drug List.

  • Self-administered (pharmacy benefit)
    • Coverage under the pharmacy benefit requires that the medications designated with a "†" symbol on the specialty drug list must be ordered from Accredo. To order, call toll-free 877-988-0059 between 8 a.m. and 8 p.m., Eastern Time, Monday through Friday – or just have your doctor contact Accredo at 800-987-4904. Provider-administered (medical benefit)
    • Preferred specialty medications covered under the pharmacy benefit are subject to 25 percent coinsurance per 30-day supply up to $100 maximum (only applies to Traditional 70/30 and Enhanced 80/20 Plans).
    • Non-preferred specialty medications covered under the pharmacy benefit are subject to 25 percent coinsurance per 30-day supply up to $150 maximum (only applies to Traditional 70/30 and Enhanced 80/20 Plans). Non-preferred specialty medications will be marked on the specialty drug list.
    • Patients administer these medications to themselves usually orally or by self-injection.
    • To obtain a prior authorization, providers may contact Express Scripts at 800-417-1764.
  • Provider-administered (medical benefit)
    • Covered under the medical benefit and subject to office charges.
    • Medications are usually administered by intramuscular injection or intravenous injection or infusion.
    • Ordered by a provider and administered under provider supervision in an office, outpatient setting or through home infusion.
    • To obtain prior authorization, providers may contact Blue Cross and Blue Shield of North Carolina Customer Service at 888-234-2416.

Using Accredo

Accredo, the State Health Plan's Specialty Pharmacy, deals exclusively with supplying medications to treat complex conditions and provides a high level of care for patients with chronic or serious conditions, who take medications that require injection, special handling and monitoring.

Plan members must use Accredo for all non-acute, self-administered specialty medications filled under the pharmacy benefit and marked on the specialty drug list with the "†" symbol. If a member uses a pharmacy other than Accredo to purchase any of the specialty medications listed and marked with a "†", they will be responsible for paying the total amount of the prescription at the time of purchase.

Services provided by Accredo include:

  • An on-call pharmacist to answer questions 24 hours a day, 7 days a week
  • Personalized counseling from a team of registered nurses and pharmacists
  • Coordination of home care and other health care services, when appropriate
  • Expedited, scheduled delivery of your medications at no additional cost
  • Refill reminder call

It's easy to get started using Accredo. There are two options to contact Accredo:

  • OPTION 1 – Call Accredo Specialty Pharmacy:
    • Step 1: Call Accredo toll-free at 877-988-0059 between 8 a.m. and 8 p.m., Eastern Time, Monday through Friday.
    • Step 2: Accredo will contact your provider and start the pharmacy transition arrangements so that you can continue receiving the medications you need.
    • Step 3: Accredo will call you back to arrange delivery of your medications at a time that is convenient for you.
  • OPTION 2 – Have your provider call:
    • Step 1: Give your provider your member ID number (shown on your State Health Plan ID card), and ask him or her to call 800-987-4904. Your provider may also order your specialty medication by accessing the Accredo website, completing the condition specific form with the requested information, and then faxing the completed form to Accredo.
    • Step 2: Accredo will call you back to arrange for expedited delivery of your medications at a time that is convenient for you.

To learn more about the specialty pharmacy benefit, view the Frequently Asked Questions. To learn more about Accredo Specialty Pharmacy services, call 877-988-0059 or visit the Accredo website.

Find a Doctor