HealthChoice Policies for Filling Specialty Drug Prescriptions

Immediately upon receipt: (1) Billing and claims processing teams must update pharmacy claim submission rules in billing software to remove any automatic restrictions or steering toward mail order pharmacies for specialty drug prescriptions. (2) Verify that all retail pharmacy networks in Maryland HealthChoice plans are activated and capable of dispensing specialty drugs with required patient education and management support. (3) Update prior authorization workflows to permit claims from retail pharmacies for specialty drugs meeting COMAR 10.67.06.04H criteria (drugs requiring enhanced patient education/management OR drugs costing $600+ for 30-day supply prescribed for complex/chronic/rare conditions not typically stocked at retail). (4) Train billing and customer service staff to inform enrollees that specialty drugs can be filled at any participating retail pharmacy capable of providing required services—do not direct them to mail order only. (5) Audit recent claims denials for specialty drugs filled at retail pharmacies and reprocess if denied due to pharmacy type steering. Maryland HealthChoice plans that violate this policy by steering enrollees to mail order pharmacies may face regulatory violations. Responsible parties: Billing team, claims processing, network operations, and customer service.