What is a specialty medication?

pharmacistA specialty medication can be defined in a variety of different ways. Medicare has perhaps the simplest definition: It states that a specialty medication is any medication that costs more than $600 a month. Other businesses, such as drug manufacturers, health providers and insurance companies, typically agree these drugs are expensive and are medically necessary to either save a life or improve the quality of a patient’s life.

Most specialty medications will cost between $2,000 and $10,000 a month, while some may cost as much as $50,000 a month. The cost to each patient will depend on what type of insurance coverage that patient has.

Specialty medications that are administered by the patient are typically either oral or injectable drugs and are often approved through the patient’s prescription insurance. Specialty medications that require an infusion are typically approved through the patient’s medical insurance and can be administered at a hospital infusion center or in the patient’s home by qualified staff. There are more than 500 specialty medications and hundreds of insurance companies, so many variations and exceptions occur.

Because of the high cost of the drugs, many insurers require that specific criteria be met before a drug is covered. These requirements often include:

  • Performing a prior authorization to request coverage of the medication.
  • Having a specific disease that the drug is FDA-approved to treat.
  • Having a history of trying and failing cheaper medications.
  • Creating high out-of-pocket costs when purchasing the medication.
  • Restricting what pharmacy can dispense these medications.

A specialty pharmacy advocate such as the UK HealthCare Specialty Pharmacy is dedicated to helping you succeed with your specialty medication.

Page last updated: 1/22/2016 2:56:56 PM