What is a
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
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:
a prior authorization to request coverage of the medication.
a specific disease that the drug is FDA-approved to treat.
a history of trying and failing cheaper medications.
high out-of-pocket costs when purchasing the medication.
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.