The Power of a Referral Form in a Limited Distribution Specialty Pharmacy Network

April 27, 2021
Rami Chammas, PharmD, MPBA Candidate

A referral form is a powerful tool that can unlock many benefits and can serve as a resource for prescribers to enhance their prescribing practices.

A limited specialty drug distribution network may consist of a number of specialty pharmacies and a patient service provider. These networks are crafted by the manufacturer and are based on several factors including the quality and breadth of services provided, experience within the disease state, product special characteristics for handling, and payer contracts provided by the network constituents. In these types of models, only the contracted pharmacies have access to the product, along with the non-commercial pharmacy who may be managing free drug programs.

Many health care providers may have an existing relationship with the specialty pharmacies within a network and prefer to directly refer the patient to that pharmacy via electronic script (e-script). This takes place in certain disease states such as oncology where this relationship has already been established through previous interactions, making it difficult to enforce a mandatory HUB model where the patient must be referred to the service provider via a referral form. However, physicians that are treating other disease states that are less engrained in the specialty pharmacy model are typically more open to a direct relationship with the service provider through enrollment form referrals. Either way, a referral to the service provider may be beneficial to the patient initially or down the road as their medical journey progresses.

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A referral form, also referred to as a prescription start form, enrollment form, or treatment form, is a form that is filled out by both the health care provider and the patient to initiate the treatment process when it comes to specialty medications. Referral forms provide instructions on information to submit for treatment and usually collect patient demographic, insurance, diagnosis, and clinical information, in addition to health care provider demographic and prescription information. Benefits of leveraging a referral form to kickstart a patient’s treatment include the following:

Obtaining Patient/Caregiver Signatures for Consent

Perhaps one of the biggest benefits of submitting a referral form is obtaining the patient, caregiver, or guardian signatures for consent. Consent can be broken down in different ways based on program, but usually consists of an authorization to share protected health information, a program enrollment consent, and a marketing consent.

The authorization for use and disclosure of protected health information, also known as Health Insurance Portability and Accountability Act (HIPAA) authorization, allows the manufacturer and companies within the pharmacy network to use and disclose protected health information. This includes information provided on the referral form, prescription, insurance, medical condition information, and other information related to the patient treatment and support services provided. This authorization is important for the sharing of information that can streamline handoffs and increase communication between the different entities providing care to the patient. Although lack of this authorization does not affect the patient’s ability to receive treatment, it may affect the patient’s ability in receiving program support services.

The other form of consent is program consent, also known as program opt-in or enrollment consent. This may be combined with the health information disclosure authorization under 1 signature. It covers the ability of the patient to receive program services such as participation in free drug programs, copay and financial support, receiving educational materials, medication compliance support, patient engagement services, and other services provided by the support program.

Lastly, marketing consent, which can also be combined with program consent under 1 signature, covers marketing communications about products and services through mail, email, fax, telephone, text messages, and other means.

In some instances, the health care provider will submit the referral form without the patient being physically in the office, meaning that the referral form will be missing the patient signature. In this case, a stand-alone consent form can be sent to the patient for signature. Such a form resembles the referral form and has the consent language within it but can be abbreviated to only include the patient demographic information.

Another more efficient way to collect consent from the patient is through electronic consent (e-consent). Some service providers or specialty pharmacies can offer this service, or a vendor can be used for this capability. During the patient welcome call or shipment set up call, the patient can agree to receive a link to the e-consent platform via email or text, or it can be provided the link verbally. They can then fill out their information and submit their e-consent. The signature along with the patient’s demographics will be auto-populated onto the referral form or stand-alone consent form template for documentation and record keeping.

Enrollment or Pre-Enrollment in Program Services

 Some support programs may offer free drug programs such as Quick Start program (also known as START program, or free trial), Bridge program, or Patient Assistance Program (PAP). These programs are offered by the manufacturer and managed by the service provider.

Quick Start

Quick Start is a program for patients newly prescribed the medication that aims to improve speed to therapy by offering a fill (or multiple fills) to the patient as the specialty pharmacy works on obtaining commercial coverage. Most specialty medications, especially ones that go through a limited distribution network, require prior authorizations and sometimes go through an appeal or peer-to-peer process for approval. This may take days to weeks and delays the start of therapy. The Quick Start program is designed to offer free drug supply to initiate the patient on therapy quickly. The program can either offer a free fill up front or can require a short period of delay in obtaining commercial coverage (eg 3 to 5 days) until the patient qualifies for a fill.

Bridge Program

The Bridge program is for when patients experience a lapse in coverage. This includes an expired prior authorization that is undergoing re-approval or a change in insurance coverage. To avoid the patient experiencing a gap in therapy, a Bridge program can be offered to fill this gap with a free drug supply.

Patient Assistance Program

The PAP is for when patients are uninsured, underinsured, or get denied coverage. Depending on payer type, this program provides a free supply of drug to the patient for a pre-determined period and typically includes checks to ensure that no changes in coverage have taken place.

The referral form can be leveraged to help health care providers enroll their patients in these programs when offered. The referral form can include a non-commercial supply prescription in addition to the commercial script and the prescriber can select it to initiate the process. In some cases, the prescriber can make a proactive selection. In the case that the patient requires one of these free drug programs at any point in their therapy, these pre-selected prescriptions can be used to dispense free drug to the patient, eliminating the need to pursue a new prescription which can cause a delay in drug shipment. This process is subject to prescription expiration rules.

Collecting Financial and Insurance Information

 For some of the programs listed above, specifically the PAP, financial information may be necessary for qualification. Eligibility criteria can include income limitations based on household size. The referral form can serve to collect this information. Otherwise, financial authorization can be provided by the patient to look this information up through the credit bureau.

 Insurance information details can also be collected on the referral form or the prescriber/patient can indicate an uninsured status. Both medical and prescription insurance information can be collected for commercial coverage and free drug qualification purposes.

Diagnostic and Clinical Information

 Depending on the disease state, the referral form can include a section on diagnostic history, treatment history, and mutation testing. Diagnostic history allows for the communication of the primary diagnosis and ICD-10 code which is needed for an on/off label assessment. Treatment history and mutation testing results can be helpful when pursuing prior authorization coverage or qualifying for free drug. The referral form typically instructs the prescriber to attach the appropriate documentation for proof. If the medication is dosed based on weight, the patient weight can be reported on the referral form as well.

Prescription and Dosing Standardization

 Many specialty medications may require a titration or weight-based dosing. This leads to complicated dosing that can end up requiring prescriber follow up for clarification prior to dispensing. This can cause unwanted delays in prescription processing and initiation of therapy. The referral form presents an opportunity to standardize dosing. It can simplify the directions on the prescription by pre-populating the most common dosing schedules, quantity, and/or day supply. The prescriber can simply select a check box of the desired strength and directions, which can be much easier to interpret by the pharmacy for dispensing.

Prescriber Pharmacy Preference

 The referral form can include a pharmacy preference section for the prescriber to indicate which pharmacy they would like the referral to be triaged to. This can encourage the prescriber to refer the patient to the support program via the referral form while still indicating their pharmacy preference. However, pharmacy preference may not always be applied, especially in scenarios where the preferred pharmacy is not contracted with the patient’s payer. The service provider will then triage the referral to the appropriate pharmacy to avoid coverage delays.

Best Time to Contact and Voicemail Preference

Some additional useful information that the referral form can collect include best time to contact both the patient and the health care provider and their voicemail preferences. This is helpful for the service provider and specialty pharmacy to understand communication preferences so they can provide a better experience to patients and prescribers.

 In addition to providing general information about the program and services available to patients and providers, referral forms have many great uses that improve patient care and the patient and prescriber experience. Referral forms enable patients to receive services offered by the manufacturer that can improve access, affordability, and engagement. They can improve speed to therapy through free drug programs, allowing for proper prescribing, and collecting clinical information needed for commercial coverage approval. In conclusion, a referral form is a powerful tool that can unlock many benefits and can serve as a resource for prescribers to enhance their prescribing practices.

About the Author:

Rami Chammas is the director of pharmacy services at RareMed Solutions, the nation’s first rare disease focused specialty pharmacy HUB. Rami oversees pharmacy operations and non-commercial pharmacy program services. Before taking on this role, Rami led implementation efforts at RareMed by successfully implementing numerous patient support programs across multiple diseases states. Rami began his journey through Specialty Pharmacy at PANTHERx Rare Pharmacy, where he was involved in projects across many departments including quality, product development and strategic partnerships.

Rami received his Doctor of Pharmacy degree from the University of Pittsburgh School of Pharmacy and is currently pursuing a Master of Pharmacy Business Administration (MPBA) from the University of Pittsburgh, a 12-month, executive-style graduate education program designed for working professionals striving to be tomorrow’s leaders in the business of medicines.