Highlights of Coverage for Specialty Medications
|Coverage Tier||Tier Name||In-Network* Benefit||Out-of-Network Benefit|
|Specialty Preferred||Tier 5||You pay 10% coinsurance ($100 minimum, $300 maximum)**||You pay in full when you obtain the drugs. You then file a claim to be reimbursed for the amount the Plan would have paid to an In-Network pharmacy (in other words, the Elixir-discounted amount less your coinsurance).|
|Specialty Non-Preferred||Tier 6||You pay 20% coinsurance ($200 minimum, $600 maximum)**|
|Other Highlights||In-Network* Benefit||Out-of-Network Benefit|
|Drug Supply per Prescription||Up to a 34-day supply***|
|How to Reach Customer Service|| |
Contact Elixir Specialty (formerly known as EnvisionSpecialty) at (877) 437-9012 (toll-free)
* Specialty drugs generally are covered only when obtained from Elixir Specialty.
** The stated “minimum” coinsurance may change depending on any coupons as described in the “How Specialty Drug Coverage Works” section.
*** For certain medications, the covered drug supply may be fewer than 34 days per prescription.
How Specialty Drug Coverage Works
Specialty drugs are complex therapies and may have special storage and handling requirements. Some of these specialty drugs include costly (for example, $30,000 per month) injectable therapies and select chemotherapeutic agents. Some examples of specialty drugs are those intended to treat rheumatoid arthritis, multiple sclerosis, and hepatitis C.
Specialty Drugs are noted in the Covered Medication Search tool as either Specialty Preferred (Tier 5) or Specialty Non-Preferred (Tier 6). To be covered by the Plan, all specialty drugs require prior authorization. You or your physician can begin the authorization process by calling Elixir Customer Service toll free at (800) 361-4542. Most new prescriptions for specialty drugs will not be authorized without a prior history of non-specialty drug prescriptions that have been determined by your physician to be ineffective for treating your condition or otherwise inappropriate for you.
The amount you and the Plan each pay is a percentage (as shown above in "Highlights of Coverage for Specialty Drugs") based on the Elixir-discounted amount. In some instances, available coupons will be used to reduce this amount, which may reduce the amounts that you and the Plan pay. The availability and use of coupons will vary and may change over time.
Once authorized, specialty drugs generally are covered only when filled through Elixir Specialty.
- To contact Elixir Specialty, you can call (877) 437-9012 toll-free. You can also order specialty drugs online by logging in to your Mail Portal at elixirsolutions.com. Normally, drugs will be shipped by an overnight carrier and arrive the next day.
- Certain specialty drugs are available only through certain pharmacies and are known as limited distribution drugs (LDDs). If an LDD is authorized, the drug is covered by the Plan when filled through any specialty pharmacy that has access to the drug (contact Elixir for more information).
Note: As with other provisions, the Plan reserves the right to change or end coverage for Specialty Preferred Drugs and/or Specialty Non-Preferred Drugs at any time.