Injectable Specialty Medications
What is “specialty pharmacy?”
New drugs like Xolair® for asthma, recombinant hemophilia factors, Avonex® for multiple sclerosis, and Enbrel® for rheumatoid arthritis are rapidly transforming medicine. These new high-cost biotechnology drugs and injectable antineoplastic drugs are known as specialty pharmacy products. These drugs are a breakthrough in treatment of many chronic diseases. It is expected that 30 or more new products will become available every year. This progress comes with a high price, as most of these medicines cost more than $1,000 each month, with some costing more than $100,000 per year.
How does TRICARE cover injectable specialty medications?
Currently, TRICARE covers outpatient specialty pharmacy products in three ways:
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Administered and billed by the provider
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Administered by the provider and billed by a specialty pharmacy
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Administered by the patient and billed by a specialty pharmacy
Humana Military processes claims for specialty drugs administered by providers such as physicians and home health agencies. Allowable charges for these drugs are set by the government in the CHAMPUS maximum allowable charge (CMAC) fee schedule.
Can TRICARE provide injectable drugs to my office?
Humana Military now has a network specialty pharmacy that can dispense prescriptions for TRICARE beneficiaries to provider offices. The preferred method for ordering specialty drugs to be administered by the provider is to submit a fax order form.
Prior to November 4, 2009, beneficiaries may obtain self-administered specialty drugs through the TRICARE retail pharmacy network by calling 1 -866-DoD-TRRX ( 1-866-363-8779). See the “ Mail Order Pharmacy Specialty Medication Care Management program” in the TRICARE Program Options section for details on specialty medication services available after November 4, 2009.
The CMAC fee schedule is accessible online.
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