What do the following things have in common; Afinitor, Gleevec, Nexavar, Revlamid, Sutent, Tarceva, Temodar, Xalkori and Xeloda? If you answered “cancer drugs” you are correct. But did you also know that this class of medications, also known as “oral oncolytics,” is typically ordered, dispensed and managed by a specialty pharmacy your insurance company has contracted with to administer and oversee the usage of these medications?
In order to better understand specialty pharmacies, we must first appreciate what a specialty medication is, as specialty pharmacies are really ONLY dispensing specialty medications. For example, you wouldn’t utilize a specialty pharmacy for picking up routine medications like antibiotics, high blood pressure pills or cholesterol medications. Typically, specialty medications have a high cost (>$500 per dose or >$6000 per year). Specialty drugs are characteristically prescribed to manage complex conditions, like cancer, multiple sclerosis, growth deficiencies and hepatitis. Sometimes, medications are dispensed only by a specialty pharmacy because they require special handling, shipping or storage. The Food and Drug Administration (FDA) may have determined the medication to have certain risks that require specialized training, education and specific processes for dispensing. In addition, there would be significant financial loss if the medication was wasted, not used appropriately or stored improperly, due to the high cost of these medications.
To answer the booming need for streamlined management and dispensing of these specialty medications, the number of specialty pharmacies in the cancer care world has grown rapidly. Specialty pharmacies are not bricks and mortar establishments like CVS or Walgreens (though both CVS and Walgreens have specialty pharmacy divisions). When I do a Google search for “specialty pharmacy,” I yield some 8 million results. There is even a National Association of Specialty Pharmacies and a newsletter called “Specialty Pharmacy Times.” Chances are your prescription benefit plan has a preferred or contracted provider (or providers) designated to manage your specialty drug needs—and you might not even know it!! So how do health providers utilize specialty pharmacies to access your medications? Let’s explore…
First, we will contact the insurance company to determine coverage, benefits, copays and if prior authorization is needed. During this call, we will identify with the insurance company which specialty pharmacy is their contracted or preferred pharmacy. Not all insurances have a contracted or preferred specialty pharmacy (see HERE for a partial list of specialty pharmacies) and in this case, you or your healthcare provider may choose a specialty pharmacy provider to dispense your specialty medication.
Next, we call the prescription in to the specialty pharmacy. The pharmacy will confirm all insurance and payment information, as well as contact you to arrange for shipping and delivery. If you are unable to pay for your co-pays, some (but not all!) specialty pharmacies will work with you to identify co-pay assistance funds that can help cover the costs of your medications. If you find yourself receiving a call from a specialty pharmacy and they tell you your co-pay will be $3000 per month, be sure to call your oncology social worker or care team for further assistance in obtaining your medications.
Once the payment is processed, the pharmacy ships the drug, usually overnight or next day air, to your desired delivery address. The shipping carrier may require a signature before leaving your medications, so be sure you or someone will be home to accept delivery. Some specialty pharmacies will also ship medications to your doctor’s office or to their retail store (example: CVS Caremark specialty pharmacy will ship some drugs to their CVS stores for pick-up).
So, what’s in it for you, the patient? Specialty pharmacies advertise an organized, patient centered and coordinated system for accessing medications and helping you manage a complex medical condition. Many offer 24 hour per day pharmacist support, as well as medication and disease specific counseling. However, the financial impact of a management and cost containment system for high cost oral cancer drugs through specialty pharmacies cannot be discounted. Many “mom and pop” drug stores simply cannot afford to keep stock of these medications on hand. Larger chain pharmacies may not have the space, training or security measures in place to safe guard high cost medications. By centralizing the dispensing of these medications to specialty pharmacies, insurance companies are making an effort to make life a little easier for those who need a specialty medication and ensure they receive the extra support and education needed to take these medications successfully. The goal of the insurer, and the specialty pharmacy, is to increase adherence to oral drug regimens, increase patient engagement in the management of their illness, and improve patient outcomes.
Remember, not only are you a patient, but you are also a consumer. If you are receiving medications through a specialty pharmacy, and are dissatisfied with the service, be sure to speak up. Communicate any problems you are having with access to your medications. If you are dissatisfied with the service you are receiving from the specialty pharmacy, discuss this with your healthcare team, your insurance company and, if you have employer-sponsored insurance, you can even complain about the service to human resources at your job. Being a strong advocate for yourself and your care needs is a critical component to your cancer treatment journey. Don’t be afraid to ask for help from your social worker, cancer center pharmacist, nurse practitioner or physician. Even though there are many hoops to jump through to access your specialty medications, your medical team is deeply invested in your access to these medications as well as your ability to take them as prescribed and store them safely—this is where the specialty pharmacy can help us help you.
Click HERE for a handout on specialty pharmacies.