Specialty Drug

A specialty drug is a high-cost medication used to treat complex, chronic, or rare conditions, like cancer, rheumatoid arthritis, multiple sclerosis, hepatitis C, or HIV. These drugs often require special handling (refrigeration, injection, or infusion), may need to be administered by a health care professional, and frequently cost thousands of dollars per month.

On your plan's formulary, specialty drugs typically fall in the highest cost-sharing tier, Tier 4 or Tier 5, sometimes called the "specialty tier." Instead of a flat copay, plans usually charge coinsurance (a percentage of the drug's cost) for specialty medications. That percentage is often 25%–50%, which can mean hundreds or even thousands of dollars per prescription before you reach your out-of-pocket maximum.

All ACA plans have an out-of-pocket maximum ($10,600 individual / $21,200 family in 2026), which limits your total annual spending on covered services including specialty drugs. Once you hit that cap, your plan pays 100%. For people on expensive specialty medications, reaching the out-of-pocket max early in the year is common.

Many drug manufacturers offer copay assistance programs or patient assistance programs that can help cover your share. Your insurer may also have a specialty pharmacy that you're required to use, which can sometimes offer lower costs.

If your plan uses step therapy (requiring you to try cheaper drugs first) or requires preauthorization for specialty drugs, ask your doctor to submit the necessary paperwork early to avoid delays in getting your medication.