What is Specialty Pharmacy? I have been a pharmacist for more than 25 years and since I started working within the specialty pharmacy arena in 2006, it has changed dramatically over the years. In 2006, not many people had previously heard of specialty pharmacy, although the practice has been around since the 1970s. At that time, there were only a few specialty drugs available, and they were typically dispensed out of a regular pharmacy (perhaps in a small section of the business). Today, however, we recognize specialty pharmacy as a vital branch of this profession that provides medications for people with complex or rare diseases that require challenging treatment modalities.
Frequently, these protocols call for high-dollar amount drug treatment plans. The complex diseases most specialty pharmacies service include, but are not limited to, cancer, HIV/AIDS, hepatitis C, rheumatoid arthritis, psoriasis, Crohn’s disease, multiple sclerosis, cystic fibrosis, organ transplantation, human growth hormone deficiencies, hemophilia, and other bleeding disorders. The goals of specialty pharmacy include helping these patients navigate their difficult disease states and treatment options by assisting them with access to these drugs, providing financial assistance to reduce the high costs, and offering tools to assist with medication adherence and compliance.
Many specialty drugs are limited to specific specialty pharmacies to ensure that the patients prescribed such medications are guaranteed access to these drugs. This makes it much easier for prescribers, patients, caregivers, and the manufacturers to track patients’ progress with their treatments. By limiting their distribution to certain pharmacies, providers can be confident that patients who start these new medications will complete the proper treatment guidelines.
Less than 2% of the population uses specialty drugs, however, those prescriptions account for a staggering 51% of total pharmacy spending (Evernorth Book of Business, 2021). In 2019, the average annual cost for one specialty medication used on a chronic basis was $84,442 (AARP Press Room 9/28/2021). Due to the typically exorbitant price tag, the pharmacy and/or medical insurance will often deny payment upon the initial claim submission. This usually causes the pharmacy staff to work with the providers to file for a prior authorization and/or appeals processes to get the claim(s) covered.
Once the medication is approved by insurance to be dispensed, the copay can still be unaffordable for many patients. Fortunately, specialty pharmacies are equipped with well-trained staff who can work to provide financial assistance to help offset these high copay amounts. They work with manufacturers for copay assistance or potential free drug program as well as multiple funding organizations that provide access to grants.
The greatest benefit of specialty pharmacy for patients is the high level of customer service provided that traditional pharmacies may not be equipped to offer. Frequent communication between pharmacy personnel and patients helps to ensure that medications are being taken properly, side effects are being managed appropriately, and that compliance to specific treatment plans is being adhered to.
On average, 6 out of 10 medications are not taken correctly. With the heightened level of customer service that specialty pharmacy provides, this statistic can improve amongst these high-cost drugs. Specialty pharmacies work tirelessly to not waste these costly medications, often times only dispensing a 15-day supply (versus a 30-day supply) to verify that a patient is able to tolerate the medication. The manufacturers of specialty drugs work closely with specialty pharmacies throughout the entire dispensing process. They want to ensure patients have appropriate access to and education of their medications for optimal outcomes.
The future of specialty pharmacy continues to evolve. The availability of specialty drugs continues to expand, generic drug players have entered the specialty market, and now pharmacy benefit managers (PBMs – pharmacy insurance companies) have their own specialty pharmacies. The hopes are that drug access is not limited for the future. Specialty pharmacy will continue to progress, partnering with manufacturers, providers, and patients to meet their needs in the ever-changing world of healthcare. AssureCare is a population health management company that uses technology to help customers make data driven decisions to solve many of these healthcare challenges. Our newest solution offers workflow enhancements designed specifically for specialty pharmacy. Click here to stay abreast of our specialty pharmacy updates.