Understanding Specialty Pharmacy (Part 2): The Patient Journey

Read Understanding Specialty Pharmacy Part 1 here.

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 finally the medication can be filled and shipped to the patient.

Check back next week for Understanding Specialty Pharmacy Part 3: Intersections With Retail Pharmacy.

About the Author

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.