What is a Specialty Pharmaceutical?
Specialty pharmaceuticals are a group of high-cost medicines that are used to treat chronic health problems. These therapies tend to be more complicated and more costly than others. They may require special storage, regular lab testing, screening tests and may be given by injection or orally. To get the most benefit, regular adherence to the regimen is needed.
What is the Gundersen Health Plan Specialty Pharmaceutical Program?
The Specialty Pharmaceutical Program gives high-quality clinical monitoring to patients using approved medications. The goal is to help the patients stay healthy and keep coverage of these medicines affordable.
Beginning on January 1, 2017, specialty medications will only be covered when provided by a pharmacy in the Specialty Pharmaceutical Program. Members will not be charged for shipping by standard mail. The medicine may also be picked up at the pharmacy.
Some examples of drug classes in this program include:
- Some HIV Therapies
- Some Oral Oncology Medications
- Growth Hormones
- Hepatitis C Agents
- Multiple Sclerosis Agents
- Biologic Response Modifiers (used for rheumatoid arthritis, Crohn's disease and others)
To see if your medication is part of the program, check the Gundersen Health Plan formulary. Medications included in this program are noted as being Tier 4 (Specialty).
Please note: this program does not apply to drugs given by a doctor or nurse in a clinic, hospital or other health care facility.
How to get your medicines from the Specialty Pharmaceutical Program:
1. If the medication requires a Prior Authorization, have your doctor or nurse submit a Prior Authorization Form.
2. If your medication is approved, call UW Health Pharmacy (866-894-3784) or Gundersen Clinic Pharmacy (877-208-1096) to start the enrollment process.
3. Answer the questions from the pharmacy staff. They will also discuss delivery or pick-up. They will contact your provider to get a prescription order for the medication.
This program DOES NOT apply to members covered under the State of Wisconsin Health Insurance Program, who have Navitus for their drug benefit or those members with BadgerCare Plus.
Any Wisconsin pharmacy that is in Gundersen Health Plan’s participating pharmacy network and can meet the terms and conditions can participate in Gundersen Health Plan Specialty Pharmaceutical Program.
Pharmacies may contact the Gundersen Health Plan Pharmacy Department at 608-775-0173 for a copy of the terms and conditions or to apply to participate.