Guide to drug coverage under medical benefit

Prescription drugs are covered in two ways—through the Healthy Blue pharmacy benefit or via medical benefit. The method of coverage depends on whether the drug is self-administered or administered by a health care professional at home (ex. home infusion therapy) or given in a clinical setting like a doctor’s office.

Drugs that are only administered to members by healthcare professionals are available under the medical benefit and can be obtained in several ways:

• Buy and Bill: Physicians may purchase drugs directly through pharmaceutical wholesalers and distributors and submit a claim to Healthy Blue. To review the list of services and drugs that are billable on the medical benefit for Healthy Blue please refer to the State Fee Schedule
• Delivery: Physicians may request delivery of a member specific specialty medication that will be administered in his or her office, by calling Healthy Blue contracted Medical Specialty Pharmacy (MSP), CVS Specialty^®
• Referral: Physicians may refer their members to infusion suites and outpatient hospital services

For more information on the North Carolina Physician Administered Drug Program (PDP), please visit the Physician Administered Drug Program page.

For more information on self-administered prescription drugs and pharmacy benefit coverage, please visit our Healthy Blue pharmacy page.

CVS Specialty^® is an independent company providing pharmacy services on behalf of Healthy Blue.

Medical Specialty Pharmacy (MSP)

Healthy Blue is pleased to announce a drug delivery option that enhances medication accessibility to both members and providers. Healthy Blue is contracted with CVS Specialty^® as the MSP. CVS Specialty^® can deliver member specific medication that is covered under the Healthy Blue medical benefit to your office for administration to the member.

MSP Delivery of medication

To set up delivery or check a prescription order status please call 877-254-0015 and you will be transferred to a pharmacist for a verbal prescription order. Please plan to provide your member's Healthy Blue ID located on their ID card. Staff will obtain additional information necessary to support the delivery of the medication, including the need by date. Please allow up to 10 days for processing and shipping. The staff will then make an outbound call to your member to obtain consent as needed to support the delivery of the medication to your office. Once all necessary information is obtained for shipping, the staff will make an outbound call to your office to confirm delivery.

You may also fax prescription orders to 866-336-8479, and a staff member will call your office to obtain additional information necessary to support the delivery of the medication as described above.

Note: If it is an urgent medication request and the need by date is less than 7 days from the order date, please indicate this, so the order can be expedited.

Home infusion therapy (HIT)

Home infusion therapy is the administration of prescription legend drugs through intravenous, intraspinal, epidural, or subcutaneous routes from the comfort of the member’s home. HIT is prescribed by a physician that both the physician and Healthy Blue have determined to be medically necessary and must supervised by a qualified health care professional to the member in their residence.

To find an in-network HIT provider please use our Find a Pharmacy tool.

Tools and medical coverage resources

Find a Pharmacy

Need to get a specialty prescription filled or find an in-network provider? Find a plan pharmacy nearby.