Specialty Drugs - Benefit Assignment and Prior Authorization Listing
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Defines the list of specialty drugs, their benefit assignment (medical vs pharmacy), prior authorization requirements, and therapeutic categories; applies to members whose plans include CareFirst benefits and to in-network specialty pharmacy fulfillment. Contact information for CVS Specialty is provided for access questions.
No material clinical or coverage changes in this revision.
Coverage guidance and specialty drug listings
Coverage guidance for listed specialty drugs
Coverage and fulfillment notes for specialty drugs listed.
Specialty drug listing (partial)
Each listed drug entry includes: Benefit Assignment, Prior Authorization Requirement, Therapeutic Category. Entries may include flags for self-injectable or limited access and special prior authorization notations.
Per-drug assignment entries (examples)
Per-drug entries (partial list) specifying benefit assignment, prior authorization requirement, and therapeutic category. Examples from this segment:
Sample drug-specific coverage entries
Per-drug routing and authorization requirements (listing excerpt):
Per-drug entries (examples)
Per-drug coverage assignment and PA requirement entries (partial list). Each line lists: Drug name, Benefit Assignment, Prior Authorization Requirement, Therapeutic Category.
Per-drug coverage assignment (excerpt)
Per-drug lines list benefit assignment, prior authorization requirement, and therapeutic category. Example entries include TASCENSO (Rx, MS), TECENTRIQ (MB, oncology, MB^), TREMFYA (Both, Rx and MB prior auth), etc.
Member coverage caveat
Coverage and utilization management are dependent on the member's specific benefit plan and may not be guaranteed by appearance on this list; members should confirm via My Account or plan materials.
Benefit assignment codes, flags and annotations
| MB | Medical benefit only |
| Rx | Pharmacy benefit only |
| Both | Medical and Pharmacy benefit |
| Rx# | Prior authorization also required if accessed on medical benefit |
| MB^ | Prior authorization required with site of care steerage on medical benefit |
| † | Limited Access - contact CVS Specialty for fulfillment options |
| * | Self injectable |
| MB | Medical benefit only |
| Rx | Pharmacy benefit only |
| Both | Medical and Pharmacy benefit |
| * | Self injectable |
| † | Limited Access - contact CVS Specialty |
| Rx# | Prior authorization also required if accessed on medical benefit |
| MB^ | Prior authorization required with site of care steerage on medical benefit |
| MB | Medical benefit only |
| Rx | Pharmacy benefit only |
| Both | Medical and Pharmacy benefit |
| MB^ | Medical benefit with site-of-care steerage (prior authorization variant) |
| Rx# | Prior authorization required on pharmacy and also if accessed on medical benefit |
| * | Self injectable |
| † | Limited Access - contact CVS Specialty for fulfillment options |
| No formal billing or CPT/HCPCS/ICD codes listed in this section; entries are drug names with benefit and prior auth indicators |
| No specific procedure or drug codes (CPT/HCPCS/NDC/ICD-10) are provided in this section. |
| No billing or procedure codes provided in this excerpt. |
| No billing or procedure codes provided in this section. |
Prior authorization, fulfillment, and access instructions
Prior Authorization definitions and codes
Prior Authorization: For specialty drugs listed below, the document uses notation to indicate whether a prior authorization (PA) is required on the pharmacy benefit, medical benefit, or both. Providers must follow the PA requirements for the assigned benefit when requesting prior authorization.
- Rx = Prior Authorization required on pharmacy benefit
- Rx# = Prior Authorization also required if accessed on medical benefit
- MB = Prior Authorization required on medical benefit
- MB^ = Prior Authorization required on medical benefit with site-of-care steerage
Fulfillment / Access flags
Benefit assignment and access indicators shown on the specialty drug list: providers should use these to determine where the drug is billed and whether PA applies.
- Benefit Assignment values: MB = Medical benefit only; Rx = Pharmacy benefit only; Both = Medical and Pharmacy benefit
- Special fulfillment flags: * = Self injectable; † = Limited Access — contact CVS Specialty for fulfillment options
- Unless otherwise noted, drugs assigned to the pharmacy benefit must be filled at an in‑network specialty pharmacy. For questions about access options contact CVS Specialty at 855-264-3237
Prior Authorization flags and meanings
Prior authorization presence and meaning indicators appear throughout the product list. Confirm the designation for each product before initiating treatment or claims submission to avoid denials or incorrect benefit routing.
- PA indicators seen in the list include: Rx, Rx#, MB, MB^, blank (no PA specified)
- Some products are listed as Both with PA on one or both benefits (e.g., “Rx, MB” or “Rx, MB^”) — follow the PA rules for the benefit being used
- When a product is assigned to Rx but shows Rx#, a PA may be required for medical-administered dosing — submit PA to the medical benefit if the drug will be provided in a clinical setting
Fulfillment and access notes
Special fulfillment and administration notes used in the list indicate whether a drug is a self-injectable and whether fulfillment is limited or requires specialty pharmacy coordination.
- * = Self injectable (member may self-administer; benefit assignment still determines where filled/billed)
- † = Limited Access — contact CVS Specialty for fulfillment options and to confirm whether on‑site administration or limited vendor distribution applies
Benefit assignment and PA per drug (partial list)
Example product-level benefit assignment and prior authorization requirements (partial list). This consolidates sample entries from the specialty drug listing to show how benefit and PA notations appear on product lines.
- ABECMA — Benefit Assignment = MB; Prior Authorization Requirement = MB
- ABRAXANE — Benefit Assignment = MB; Prior Authorization Requirement = MB
- ACTEMRA — Benefit Assignment = Both*; Prior Authorization Requirement = Rx, MB^
- ACTHAR — Benefit Assignment = Rx*; Prior Authorization Requirement = Rx#
- COSENTYX — Benefit Assignment = Both*; Prior Authorization Requirement = Rx, MB
- CRYSVITA — Benefit Assignment = MB; Prior Authorization Requirement = MB^
- POMBILITI — Benefit Assignment = MB; Prior Authorization Requirement = MB^
- RADICAVA — Benefit Assignment = Both; Prior Authorization Requirement = Rx, MB^
- STELARA — Benefit Assignment = Both*; Prior Authorization Requirement = Rx, MB
- ZILBRYSQ — Benefit Assignment = Rx*†; Prior Authorization Requirement = Rx#
Provider next steps and language access
Provider actions and contacts: confirm benefit assignment and PA indicators on the product list before prescribing or arranging administration. Use the specialty pharmacy contact for fulfillment questions and for limited-access products. Language interpretation services are available at no cost.
- If drug is assigned to Rx, fill at an in-network specialty pharmacy unless otherwise noted; contact CVS Specialty at 855-264-3237 for fulfillment options
- If PA is indicated as MB or MB^, submit PA through the medical prior authorization process used by CareFirst (follow site-of-care steerage when MB^ is shown)
- For Limited Access (†) products, contact CVS Specialty to determine approved fulfillment channels and any vendor-specific requirements
- Free language interpretation and translation services: members should call the number on the back of their member ID card. All others may call 855-258-6518 and follow prompts (press 0 when prompted) to be connected to an interpreter
Definitions and annotation keys
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