The PerformRx Specialty Drug Program
Specialty and injectable drugs are a medical benefit that is managed by the PerformRx Prior Authorization Specialty Drug Program. Exceptions include diabetic (insulin related) injectables and certain non-specialty injectable medications. The Specialty Drug Program reviews requests for specialty and injectable drugs administered in a member's home or a physician's office.
Specialty drugs include unusually high-cost oral, inhaled, injectable, and infused pharmaceuticals prescribed for a relatively narrow spectrum of diseases and conditions. Additionally, these products typically have very specific clinical criteria and prescribing guidelines that must be followed to ensure appropriate use and outcome.
Compliance with these criteria is managed through the Prior Authorization process. Unless otherwise specified, injectable drugs managed by the PerformRx Specialty Drug Program require prior authorization. Injectable drugs that are incidental to and administered during an inpatient hospital or hospital-based clinic stay are not managed through PerformRx Specialty Drug Program and may not require prior authorization.
Our Injectable Program comprehensively focuses on those medications and treatments that represent a potentially high impact on patient health, safety or welfare. The goal of the program is to control and facilitate use and distribution of the medication, resulting in improved patient outcomes and minimal waste.
Key aspects of this program are:
- Intensive clinical review based on approved protocols for usage
- Specialty network management
- Electronic claims adjudication
- Utilization management
The PerformRx Specialty Drug Program provides replacement of drugs administered in a physician's office, and injectable medications dispensed through network specialty or retail pharmacies for patient self-administration. Nurse case management for bleeding disorders, inpatient high cost drug carve-out management, and home infusion medication management are some additional facets of this important clinical program.
