What Are Specialty Pharmacies?
Key takeaways:
A specialty pharmacy offers services and medications to help treat rare and complex medical conditions like cancer, rheumatoid arthritis, and multiple sclerosis.
Many medications that specialty pharmacies provide need special handling, storage, and administration.
Specialty medications are usually expensive and require prior authorizations by insurance companies.
People who have complex medical conditions — such as rheumatoid arthritis and multiple sclerosis — can often feel overwhelmed. Part of this feeling can come from keeping track of their medications. The costs associated with these conditions don’t make things easier. This is when specialty pharmacies can step in and help.
Compared to traditional pharmacies, specialty pharmacies can provide more comprehensive services to people with these conditions. These services may begin when you’re diagnosed and continue long after the medication has left the pharmacy. Examples of services may include handling billing and making sure you stay on track with your medications.
Read on to find out how specialty pharmacies work and how they differ from traditional retail pharmacies.
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What types of medications do specialty pharmacies dispense?
Specialty pharmacies mainly deal with medications that treat complicated or rare health conditions. These are known as specialty medications.
There isn't one set definition of a specialty medication. But here are some of their characteristics:
They are generally very expensive and may cost $670 or more per treatment. Specialty medications account for at least 50% of medication spending per year.
They may require special handling, administration, or storage.
You may need thorough training before you can safely use specialty medications.
A healthcare provider may need to administer your dose. They may also need to watch you in case you have serious side effects afterwards.
Many specialty medications are biologics. They could be injectable, oral, or intravenous (IV) infusion products.
Medication manufacturers may make only certain amounts of the specialty medications. And specialty pharmacies may be the only pharmacies allowed to order them.
What conditions often require using a specialty pharmacy?
People with conditions that have high risks of complications may need to use a specialty pharmacy. Specialty medications often have more risks of serious side effects than other medications.
Examples of such high-risk conditions include:
Cancer
Multiple sclerosis
Rheumatoid arthritis
Inflammatory bowel disease, such as Crohn’s disease and ulcerative colitis
Blood clotting disorders, such as hemophilia
Staying on track with medications improves the quality and length of life for people with these conditions. Specialty pharmacies can provide the support these people may need.
What’s the difference between a regular pharmacy and a specialty pharmacy?
If you’ve ever had to fill a prescription medication, then you’ve probably visited a retail (community) pharmacy. This type of pharmacy can be a stand-alone business. But it can also be in a grocery store, big-box retailer, or hospital. You might have also used a mail-order pharmacy that’s similar to a retail pharmacy.
Retail pharmacies stock a variety of prescription and over-the-counter (OTC) medications. Some may also have specialty medications but in limited amounts.
Before dispensing a medication, a retail pharmacist checks for allergies and drug interactions. They also make sure the medication is safe based on your age, medical condition(s), and other factors.
A retail pharmacist may notify healthcare providers if there’s a problem billing insurance. Examples include prior authorizations or medications that aren’t covered. Once a medication leaves a retail pharmacy, pharmacists often don’t have time or aren’t required to follow up with people.
A specialty pharmacy mostly follows the same process: Pharmacists also check the medication dosage, allergies, and drug interactions before dispensing prescriptions. But otherwise, the steps taken look a little different.
Most specialty pharmacies deliver medications by mail. But some may offer in-person pickup. A specialty pharmacy is also much more involved in treatment. That’s because missing doses could cause serious problems for people with complex medical conditions.
As mentioned above, specialty medications may require special storage. This may include making sure the medication stays cold until you receive it. Specialty pharmacies have the proper equipment to make sure your medication stays at the right temperature.
Specialty pharmacies also offer financial help if you can’t afford your medications. Manufacturer patient assistance programs and copay cards are two examples. Specialty pharmacies often have better access to these programs than retail pharmacies.
Lastly, they provide support throughout your treatment. This helps ensure safe medication use. Specialty pharmacies conduct regular follow-ups with you. This helps them watch for side effects and treatment response. Follow-ups can be done by telephone or in person, based on which is more convenient.
This higher, more personalized level of care is the main difference between retail and specialty pharmacies.
How do you choose a specialty pharmacy?
Typically, your insurance company will have a preferred specialty pharmacy network that you’ll use. You may have a few different specialty pharmacy options, or you may have just one. It varies based on your insurance plan. Healthcare providers may also have a certain pharmacy that they will refer you to.
It’s best to check with your insurance company ahead of time. Ask which specialty pharmacies you can use. It’s best to do this before your healthcare provider sends a referral or prescription to one. This will help to make the process a lot easier.
Do you need a referral to access a specialty pharmacy?
You don’t need a referral to use a specialty pharmacy. If you want to, you can call a specialty pharmacy and ask to get your medications filled there. They’ll gather the information they need to get you started.
But a referral from your healthcare provider is more efficient. Your healthcare provider’s office will complete a referral form, which may include:
Your basic personal information (e.g., name, date of birth)
Insurance information
Healthcare provider’s information
Treatment plan
Certain lab results
Other information about your medical condition and treatment
A referral provides a specialty pharmacy with more complete information about your background. This helps them know if a medication is safe for you. They’ll use your insurance information provided to find out if the medication is covered.
Depending on the insurance company's response, the pharmacy may:
Ask your healthcare provider to complete a prior authorization
Recommend an alternative medication to your healthcare provider
Provide you with financial help for the medication
Work with your healthcare provider to submit a letter of medical necessity to the insurance company
A referral form may include the prescription from your healthcare provider. But your provider can separately fax, call, or electronically send in the prescription.
Can you use your health insurance at a specialty pharmacy in the same ways as at a retail pharmacy?
Specialty pharmacies can bill both prescription insurance and medical insurance. This is different from retail pharmacies, which usually only bill prescription insurance plans. The type of medication you need will determine which plan is billed.
Prescription plans usually cover medications that you take by mouth or self-inject. Medical plans are more likely to cover IV medications or injections a healthcare provider gives you.
Many of these medications need prior authorizations because they’re so expensive. Even if the insurance company covers it, your copay may still be quite high.
Specialty medications’ price tags can be daunting. This is especially true if you don’t have insurance. As mentioned above, specialty pharmacies help provide financial help. One of their goals is to help people afford these expensive medications. Most specialty pharmacies have dedicated teams that help lower medication costs.
The bottom line
People with certain medical conditions have higher risks for complications. Using their medications as prescribed is very important. Unfortunately, specialty medications that treat these conditions are usually very expensive. People often need help to afford them.
A specialty pharmacy can provide financial resources. This is one of many traits that sets them apart from other pharmacies — and which may make them the best option for you.
Why trust our experts?
References
American Society of Health-System Pharmacists. (2020). ASHP accreditation standard for specialty pharmacy practice.
Cassano, A., et al. (2015). ASHP specialty pharmacy resource guide. American Society of Health-System Pharmacists.
Chambers, J. D., et al. (2018). Specialty drug coverage varies across commercial health plans in the US. Health Affairs.
Cubanski, J., et al. (2019). The out-of-pocket cost burden for specialty drugs in Medicare Part D in 2019. Kaiser Family Foundation.
HealthEquity. (2021). Letter of medical necessity.
Hirsch, B. R., et al. (2014). The impact of specialty pharmaceuticals as drivers of health care costs. Health Affairs.
National Association of Specialty Pharmacy. (2018). What is specialty pharmacy?
Zuckerman, A. D., et al. (2019). An integrated health-system specialty pharmacy model for coordinating transitions of care: Specialty medication challenges and specialty pharmacist opportunities. Pharmacy (Basel, Switzerland).
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