Molly C. Gombos, PharmD, MPBA Candidate

If we consider the world of specialty pharmacy through the eyes of retail pharmacists, there are a few frustration points.

As we touched on when introducing specialty pharmacy, there is no universal list of specialty medications, which can cause a disconnect when coordinating care between prescribers, pharmacies, payers, and patients. A physician may prescribe some specialty medications unknowingly to the local pharmacy and later the patient may find that their insurance plan requires it to be filled through a specialty pharmacy, even though the retail pharmacy has a bottle in stock. This can happen often because 1 payer may identify different drugs as specialty than another. Explaining this rejection to a patient becomes challenging and can be frustrating for pharmacists who may feel it is more practical and beneficial to fill the prescription at the retail store. Additionally, the extent to which individual retail pharmacies may stock or be able to order specialty medications may also differ greatly from one to the next as well, depending on many factors. This can cause further confusion and frustration for prescribers and patients looking to find the medication locally. Similarly, a pharmacy may go from being able to fill a drug one day to requiring a transfer to a specialty pharmacy for the next fill because of availability, company policy change, or due to plan requirements. 

Even though there are these few points of frustration and potential knowledge gaps, retail pharmacists are typically much more familiar with specialty pharmacy than a consumer. As we know, specialty pharmacy is one of the newest and most successful branches of pharmacy and is rapidly growing, but many consumers still know so little, if anything about it. 

So, the question becomes: how can retail pharmacists support new-to-specialty patients and thus specialty pharmacies? 

Most of this support comes in the form of retail pharmacists doing something they are already inherently good at: providing patients with counseling and a listening ear as they begin this new, complicated journey. Retail pharmacists are some of the most accessible and trusted health care providers in the country and in some scenarios may be the first person to realize that a patient’s therapy will require specialty pharmacy. Pharmacists can help their patients who are new to specialty by simply explaining why a medication may require a specialty pharmacy and what the patient may expect, then recommending and transferring the prescription to a specialty pharmacy if possible. Also, in some cases, retail pharmacists can help by contacting the patient’s insurance provider to learn more about potential rejections, or simply by putting them in touch with someone else who may be able to help them more. 

A model becoming more popular in the industry that has helped retail pharmacists support patients as well as simplify the conversion process is specialty pharmacies affiliated with pharmacy benefits managers and/or retail pharmacy chains. These models can make it especially easy for a patient to get their specialty medication if they are already getting other medications from an affiliated retail pharmacy. This is because the company will usually have demographic and insurance information for the patient and can often automatically complete the prescription transfer. As you can see, there is much being done to integrate the worlds of retail and specialty pharmacy, but there is still work to be done to make this process even smoother for new patients. Though the specialty pharmacy model may be complex, one thing is quite clear: these pharmacies provide a vital service to patients and fill an otherwise unmet need in the industry. As we’ve discussed here, there are many things retail pharmacists can do to support their patients who, likely more than ever, will need this counseling and expertise. 

Molly Gombos earned her Doctor of Pharmacy degree from the University of Pittsburgh in 2014 and is currently enrolled at Pitt in the Master of Pharmacy Business Administration (MPBA) program, a 12-month, executive-style graduate education program designed for working professionals striving to be tomorrow’s leaders in the business of medicines. Molly has spent the last 7 years working in community pharmacy, initially as a pharmacist and pharmacy manager and most recently working in pharmacy operations. Her current role is working in the patient safety and clinical space with focus on clinical decision support.

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If we consider the world of specialty pharmacy through the eyes of retail pharmacists, there are a few frustration points. 

Understanding Specialty Pharmacy (Part 3): Intersections With Retail Pharmacy

Now, let’s consider the world of specialty pharmacy from a patient’s perspective. 

You’ve gone to the same pharmacy for 20 years and now you are prescribed a new medication for a likely scary condition or disease that you cannot pick up from your neighborhood pharmacy. This may be uncomfortable or overwhelming, if not terrifying for patients. As we know, traditional prescriptions usually follow a process that often looks something like the patient’s provider sending a prescription to the patient’s pharmacy of choice where the patient simply goes to pick up the prescription after the pharmacy quickly completes the fill. This is quite a simple process that has been around for decades. While there are some industry disruptors hoping to break this mold and define a new, more convenient normal for retail pharmacy, this remains by far the most commonly utilized path for patients.

Now, consider the journey a specialty patient will follow to ultimately receive their medication. The journey is often complicated from the very beginning, as most specialty medications treat complex disease states that are hard to diagnose. This means that patients are often tired and frustrated before they even have a diagnosis, let alone a filled prescription. Once these patients have seen a specialist, endured the testing and appointments required to get an accurate diagnosis, and received a prescription, they are more than ready to begin their treatment. Unfortunately, however, this typically is not the end of the complicated journey. Depending on the provider, the medication, and the patient’s insurer, the actual prescription may be sent directly to a specialty pharmacy or it may not, as there is no standard list of specialty medications and it varies significantly from payer to payer. Sometimes it takes a rejected claim at a retail pharmacy for the patient to learn that they have been prescribed a specialty medication. At this point, the patient would need to begin navigating the prescription transfer process and/or communicating with the provider again to ensure the prescription makes it to the right place. 

Now, once the prescription does reach a specialty pharmacy, this journey is usually still not a simple one. The specialty pharmacy will need to verify the patient’s benefits, which can take several days depending on the situation, and then the pharmacy can bill the claim. As mentioned previously, it will be highly likely that the prescription will need a PA at this point, which will require the pharmacy to work with the prescriber and the payer to receive authorization. The amount of time the PA process takes varies greatly; however, once the authorization is received, the patient will be appropriately educated and counseled, and then 

 the medication can be filled and shipped to the patient.

Understanding Specialty Pharmacy Part 3: Intersections With Retail Pharmacy. 

Let’s consider the world of specialty pharmacy from a patient’s perspective. 

Understanding Specialty Pharmacy (Part 2): The Patient Journey 

The field of specialty pharmacy is exactly what it sounds like—it is a unique, rapidly growing segment of the pharmacy industry that primarily focuses on the dispensing of high-cost, high-touch medications.

High cost, in this instance, typically refers to therapies that cost upwards of $700 per month for a patient—simple enough, right? Defining “high touch” is a little bit more obscure. Think of it as analogous to being considered “high maintenance”. For our purposes, this translates to medications that require extra time, attention, and/or resources from most or all the stakeholders associated with it from production to consumption, namely manufacturers, wholesalers, prescribers, payers, pharmacies, and patients. Specialty medications are also “special” in that they often tend to treat disease states that affect smaller patient populations than those most often seen at traditional retail pharmacies. For example, according to the American Heart Association, in 2020 an estimated 918 million individuals globally are living with a diagnosis and/or are being treated for hypertension. Conversely, according to the National Multiple Sclerosis Society, only 2.8 million people worldwide suffer from multiple sclerosis, a common disease state targeted by specialty medications. Additionally, therapies 

 also be considered specialty medications when they are prescribed only by specialists and/or are restricted from a distribution standpoint. Other specialty medications may include biotech products, medications that require special handling, products with unique administration routes such as injectables, or drugs that are included and restricted by a Risk Evaluation and Mitigation Strategy program and require extra monitoring. There is no exhaustive drug list or 1 set of criteria that specifically defines which medications are considered specialty medications. Different organizations or companies may have completely different lists or criteria from one another for the medications that they require to be dispensed in a specialty pharmacy, thus making this industry even more complex and tricky to define and conceptualize. 

As we know, the concept of pharmacies, drug stores, and apothecaries have existed since ancient times with traditional pharmacies operating in most cities, towns, and villages for many, many decades. The concept of specialty pharmacies, however, has only come into existence in much more recent times, beginning in the 1970s, and has been in much more focus over the last decade or so. 

Specialty pharmacy models first originated from the need to better support and manage the medication therapy of primarily transplant and HIV patients. The relatively new-to-market, complex medications used to treat these disease states were generally higher cost and required more patient counseling regarding proper use, the importance of compliance, and the adverse effects compared with typical new-to-market medications. Dispensing these medications in pharmacies specifically equipped and trained to handle this new level of complexity resulted in a higher level of care for patients and, often, better outcomes. From there, specialty pharmacy has continued to grow over the years to include hundreds of additional drugs for similarly complex disease states such as pulmonary hypertension, immune disorders, and many more. This niche industry also began to add a focus on drugs for exceedingly rare and orphan diseases to facilitate a higher level of expert care for patients from pharmacists specially trained and educated on these smaller groups of medications than a traditional retail or mail order pharmacist.

Helping Retail and Specialty Pharmacies Use the Right Analytics to Unlock Value Beyond Prescription Reimbursements 

As the specialty model has gained more volume, attention, and success, this newer branch of the pharmacy industry has grown tremendously over the past few decades. This is no surprise as these licensed, accredited pharmacies offer a traditional, yet unique service to patients by dispensing medications when needed while also providing much more personalized medication counseling, adherence coaching, and third-party support – something today’s retail pharmacies are not structured to routinely provide at such a high level. This is not to suggest that retail pharmacists are not capable of providing quality patient care and experiences, but simply that the time associated with these processes for specialty drugs often exceeds the typical time required or allotted for a similar process in the community setting, referring back to the “high-touch” concept. 

Take for example billing a prescription through a patient’s insurance. In the specialty setting, approximately 85% of prescriptions require prior authorization (PA), which can take several minutes to hours between initiation, prescriber collaboration, paperwork, and follow up. This far exceeds the percentage of prescriptions that require PA at retail pharmacies by a large margin. Similarly, many contracts associated with specialty medication manufacturers require that the dispensing pharmacy ensure the highest level of patient adherence and/or provide clinical programs and support—both of which take significant pharmacist resourcing and time.

We should also consider the steep increase in specialty-type medications coming to market as the science and research on hard-to-treat conditions continues to improve year over year. It is clear how difficult and overwhelming this could quickly become in the retail setting for pharmacists to remain up-to-date and knowledgeable on each new medication hitting the market, despite rarely dispensing them. To note, overall growth in specialty pharmacy today is significantly outpacing traditional pharmacies and soon will make up approximately half of total pharmacy spend with more than half of all newly approved drugs potentially being considered specialty medications. These 2 factors, when considering the model of retail pharmacy, further highlight the need for specialty pharmacies.

Understanding Specialty Pharmacy Part 2: The Patient Journey. 

Overall growth in specialty pharmacy today is significantly outpacing traditional pharmacies and soon will make up approximately half of total pharmacy spend.