Specialty Pharmacy and Specialty Medications: What You Should Know

Roni Shye
Roni Shye, PharmD BCGP BCACP, is a licensed pharmacist in the states of Florida, Ohio, and Pennsylvania.
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You may or may not have heard the terms specialty medications or specialty pharmacy unless you are one of the people who actually needs one of these sometimes life changing medications.

First, what is a specialty pharmacy?

Most of the time, a specialty pharmacy will be different from your local retail pharmacy where you stop in to pick up your monthly blood pressure pill or the occasional antibiotic. Usually, your specialty pharmacy is assigned to you by your insurance company, and they are most often exclusively mail order pharmacies. The specialty pharmacy takes care of your prescriptions from start to finish. This means that they get the prescription from your doctor’s office, take care of any authorizations that may be needed, fill the medication, and ship it to your house or the doctor’s office for administration.

These steps seem simple enough, right? Well, sort of. There are a few other things you might need to know about specialty vs regular prescriptions:

What if I need prior authorization to fill my prescription?

As mentioned above, sometimes your medication will need permission from your insurance company better known as a prior authorization. This means that your doctor must provide some more clinical information to the insurance company before they approve your prescription to be filled.

What type of information will my doctor need to provide?

The information requested from your doctor can include blood work, specific test results, and other medications that have been tried for your condition. The authorization process can take anywhere from a few hours up to several days, sometimes longer, depending on the information needed and how quickly your doctor’s office can provide it. Once they have the information, the insurance company will either approve or deny your prescription to be filled.

My specialty medication has been DENIED—now what?

If your medication is denied, your doctor’s office has the ability to appeal the insurance company’s decision and explain why this particular medication is necessary, or the doctor can change the medication to an approved alternative that may or may not be considered a specialty medication. This is a choice that only your doctor can make based on your particular condition. Most specialty medications are very expensive and should only be tried after other options have been exhausted.

My specialty medication has been APPROVED—now what?

If your medication is approved, the specialty pharmacy will be provided with your insurance information. If you are satisfied with your co-pay, you’ll pay, order, and the filling process will take place. Your medication may need to be shipped to your home, your doctor’s office, or in a few cases, a local pharmacy; once this has been determined, it will be sent out.

What if the co-pay is too expensive—what are my options?

For the majority of specialty medications, the manufacturers are aware of their high cost and provide co-pay assistance cards to eligible patients that can lower the cost of the medication considerably. The specialty pharmacy will be aware of these discounts and should have the co-pay assistance cards on hand, so always be sure to double check that your medication has one and that it is being used for you.

Who is not eligible for co-pay assistance, and are there other assistance options?

Patients who have government funded healthcare such as Medicare or Medicaid are not eligible for manufacturer co-pay assistance cards. However, there may be foundation assistance available for you, based on your condition and financial situation. The specialty pharmacy can direct you to the various foundations that may be able to assist you in your payment for your medication. However, assistance is usually based on income and other information that only you will be able to provide, so you will need to physically apply in order to receive help from these foundations.

I do not have pharmacy insurance—how do I receive my specialty medication?

If you do not have any pharmacy benefits there are also programs from drug manufacturers that will provide access to the medication—often free of charge! Be sure to let the specialty pharmacy know if you do not have pharmacy benefits so that they may provide you with manufacturer information for these type of programs.

What should I expect once I receive the medication?

Depending on the type of medication your doctor has ordered (for example, some injectable medications) you may or may not be able to administer it yourself. Before receiving this type of medication, you will be instructed in how to use it, either by your doctor’s office, over the phone, or in person with a nurse, pharmacist, or other qualified healthcare provider.

Once I’ve started on my medication, what are the next steps?

Your specialty pharmacy will be in contact with you regarding your new medication to see how you are doing, whether you have any questions, and if you happen to be experiencing any adverse or side effects from the medication. The specialty pharmacy may also provide you with free supplies and services such as pen needles or alcohol swabs, refill reminders, and medical provider support from a nurse or pharmacist.

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