Specialty Pharmacies 101

A specialty pharmacy is a specific type of pharmacy that concentrates on offering certified pharmaceutical goods and services to patients with complex, long-term, or uncommon medical illnesses. These pharmacies frequently work with medicines that need particular administration, handling, monitoring, or patient support. Pharmacists and other healthcare professionals with in-depth knowledge and experience in managing and administering drugs used to treat particular diseases or ailments work at specialty pharmacies. These could consist of treatments for rheumatoid arthritis, multiple sclerosis, HIV/AIDS, hepatitis C, cancer, and other complicated illnesses. Specialty pharmacies provide patients with a full range of support services, such as adherence programs, medication education, and counseling. To organize patient care, respond to any worries or inquiries, and help ensure medication adherence and therapy compliance, these pharmacies work closely with healthcare providers and insurance organizations.1

Special restrictions for handling, administering, and storing specialty drugs are frequently present. These pharmacies have the facilities, tools, and training required to handle and store drugs in a safe and effective manner. They might also offer specialized packaging, including temperature-controlled packaging for medicines that need to be kept cold.2 Specialized pharmacies have experience managing the difficulties of insurance coverage and the prerequisites for prior authorization for specialized drugs. In order to secure the required approvals and facilitate patients' access to pharmaceuticals, they collaborate with healthcare providers and insurance firms. For prompt and dependable access to drugs, specialty pharmacies frequently provide specialized prescription delivery services. As seen in the patient-centric model for specialty pharmacy there are 5P’s. It provides drive adherence and persistency, proper management of medication dosing and side effects, and ensures appropriate medication use. A high-performing specialty pharmacy intersects at the “5 Ps”. The direct delivery of pharmaceuticals to patients' homes, medical facilities, or other predetermined locations may be required.2 Additionally, they might give customers access to pharmacists around-the-clock for queries about medications or emergencies.

The distribution and wholesale supply of specialty pharmaceutical products to a range of healthcare providers, including specialty pharmacies, hospitals, clinics, and other healthcare institutions, is the focus of specialty pharmacy distributors and wholesalers. The "Big Three" -- AmerisourceBergen, Cardinal Health, and McKesson -- dominate the wholesale (primary care) and generic product distribution markets, and these businesses are increasingly delivering specialty treatments.3 These distributors operate as a bridge between the producers of specialized pharmaceuticals and their consumers.

Specialist pharmacy distributors source and acquire specialist pharmaceuticals by working directly with pharmaceutical manufacturers. To guarantee a consistent supply of these particular goods, these distributors negotiate contracts and build partnerships with producers. A large variety of specialty pharmaceuticals, including expensive drugs, biologics, and other advanced treatments, are kept in stock by distributors. They take care of inventory management, tracking, and monitoring to make sure that products are available when doctors, nurses, or pharmacists place orders. Healthcare professionals or pharmacies place orders with specialty pharmacy distributors, who then pick, pack, and ship the required pharmaceuticals to complete the orders. They make sure that specialty items are handled, stored, and transported in a manner that preserves their integrity and quality throughout the distribution process. In order to provide healthcare professionals and pharmacies with efficient and dependable access to these specific pharmaceutical items, specialty pharmacy distributors play a critical role in the supply chain of specialty drugs. They help ensure that patients with complicated medical problems receive specialist pharmaceuticals by managing inventories, logistics, and regulatory compliance.

The specialty pharmacy distribution module is a framework that includes numerous organizations and procedures engaged in the delivery of specialized pharmaceuticals with the aim of assuring timely and accurate patient care. Pharmaceutical manufacturers, specialized pharmacy distributors/wholesalers, pharmaceutical manufacturers, healthcare providers, patients, and pharmacy benefit managers (PBMs) are frequently represented in this model. PBMs are companies that manage employer- or health insurance plan-sponsored prescription medication coverage programs. To get desirable prices and guarantee proper drug use, they negotiate contracts with pharmacies, specialized pharmacy distributors, and pharmaceutical manufacturers. PBMs are essential to the specialized pharmacy distribution module's management of formularies, processing of claims, and implementation of cost-control measures. As seen through the model, there is a contract responsibility between the manufacturer and the pharmacy benefit manager and the same contract between the pharmacy and the pharmacy benefit manager.

There are certain functional aspects of specialty pharmacies that are greatly affected by pharmacy benefit managers. PBMs closely collaborate with their clients to create and update a formulary, or list of approved pharmaceuticals. This entails choosing which specialty pharmaceuticals appear on the formulary and settling on prices and reimbursement amounts with drug producers.4

To ensure adequate coverage, PBMs evaluate specialty medications' clinical effectiveness, cost-effectiveness, and safety. Since specialty drugs are expensive and have particular properties, PBMs utilize usage management techniques to encourage proper use and keep costs in check. Implementing prior authorization requirements, step therapy procedures, quantity restrictions, or clinical criteria for accessing specialty medications may be necessary to achieve this. To establish whether a drug is medically required and suitable, PBMs evaluate patient-specific data and clinical evidence. PBMs are responsible for processing prescription claims for specialty drugs. They accept claims from specialty pharmacies and assess them in accordance with the requirements of the benefit plan after determining eligibility.

The patient's out-of-pocket expenses are calculated by PBMs, who also pay the pharmacy for the covered portion and handle any benefit juggling with other insurance companies. PBMs might offer patient support initiatives such as materials for patient education and medication adherence programs. By assisting people in managing side effects, understanding specialty medications, and adhering to treatment regimens, these initiatives seek to enhance patient outcomes. PBMs could supply counseling services or put patients in touch with specialized pharmacists for individualized advice. PBMs use their influence and negotiation skills to reach fair pricing agreements with pharmaceutical producers.4 By negotiating rebates, discounts, and other concessions, they try to keep costs under control. Additionally, PBMs collaborate with their clients to create benefit plans that balance cost-sharing elements like copayments and coinsurance to maintain patient affordability while controlling overall healthcare costs.

Specialty pharmacy is a subset of general pharmacy practice that concentrates on offering treatments and other services to people with intricate, extended, or unique medical illnesses. These illnesses frequently call for specialist drugs, constant observation, and rigorous patient care. Specialty pharmacies offer a variety of complete services in addition to providing pharmaceuticals, setting them apart from regular pharmacies. To guarantee optimal medication administration, adherence, and patient education, they collaborate closely with healthcare professionals, patients, and insurance companies.

References “Specialty Pharmacy.” Home, www.pharmacist.com/Practice/Patient-Care-Services/Specialty “What Are Specialty Pharmacies, and Why Do They Exist?” GoodRx, www.goodrx.com/healthcare-access/pharmacies/specialty-pharmacies. Specialty Pharmacies and Distributors - Ashp, www.ashp.org/-/media/assets/pharmacy-practice/docs/sppm-specialty-pharmacies-and-distributors.pdf PBM Basics - Pharmacists Society of the State of New York - Pssny.Org, www.pssny.org/page/PBMBasics. Specialty Pharmaceutical Distribution for Hospital Pharmacy, www.cardinalhealth.com/en/solutions/specialty-distribution.html What Is Specialty Pharmacy? - NASP, naspnet.org/wp-content/uploads/2019/08/What-Is-Specialty-Pharmacy-090718.pdf