What is a specialty pharmacy?
Specialty pharmacies were established in direct response to the industry’s need to better procure, store, and dispense specialty drugs, as well as better manage therapy for patients on specialty drugs. Among other things, these pharmacies specialize in the unique storage and shipping requirements that oral, injectable, inhalable, and infusible products require.
Pharmacists and personnel working for these specialty pharmacies provide patient education and clinical support beyond the capabilities of a traditional retail pharmacy. These pharmacists manage drug regimens for patients with complex and chronic conditions, including multiple sclerosis, hepatitis C, rheumatoid arthritis, cystic fibrosis, hemophilia, and certain forms of cancer.
Since retail and manufacturer-affiliated pharmacies are not typically equipped to manage the full range of products and services that PBMs and payers require for the distribution and management of specialty drugs, they rely on the technology and expertise of specialty pharmacies to properly dispense these drugs.
The roles of specialty pharmacies are still evolving. As the specialty drug pipeline continues to grow, so do the services required of specialty pharmacies. These pharmacies are regularly innovating to develop new capabilities that serve the evolving needs of patients, providers, payers, and drug manufacturers.
Specialty pharmacies are distinct from retail pharmacies in that they coordinate the many aspects of care for people with complex and chronic conditions, and specifically help patients with rare conditions. They also specialize in the unique storage and shipping requirements that specialty drug products require.
Coordination of Care
Specialty pharmacies lead collaborative efforts to coordinate care with other clinicians and health care professionals. They specialize in managing patients’ treatments, side effects, and interactions with other therapies. This improves clinical and economic outcomes for patients, providers, and payers.
Skilled nurses and pharmacists from specialty pharmacies offer extra support to patients with complex medical conditions including:
- Blood disorders
- Crohn’s disease
- Growth hormone deficiency
- Multiple sclerosis
- Organ transplant
- Osteoarthritis and rheumatoid arthritis
Specialty pharmacies undergo formal accreditation reviews to demonstrate their ability to meet predetermined criteria and standards established by independent, professional accrediting agencies. Although specialty pharmacy accreditation is a baseline requirement for inclusion in PBM preferred specialty pharmacy networks, it is not necessarily a requirement to dispense specialty drugs to patients.
Multiple organizations, including URAC and the Accreditation Commission for Health Care (ACHC), accredit specialty pharmacies and provide an external validation of the services offered to patients, providers, and payers. Accreditation organizations collaborate with industry experts to create standards that ensure quality is maintained throughout all aspects of pharmacy operations, patient care management, and quality improvement processes. Of the 64,000 pharmacies in the U.S., 378 have achieved specialty pharmacy accreditation from either URAC or ACHC. One-quarter of these pharmacy locations are accredited by both organizations.
Accreditation criteria do not include requirements for how economics are managed, how to carry out payer plan design, or how to encourage the lowest-cost drug option. Because of this, PBMs maintain their own criteria for specialty pharmacies to be included in their preferred networks. These criteria pick up where accreditation organizations leave off in terms of fulfilling payer and plan sponsor specialty benefit plan design.
Compared to traditional retail drugstores, mail-service and specialty pharmacies offer deeper discounts and enhanced services. Based on Visante’s analysis, this can generate substantial savings for the U.S. health care system:
- Mail-service pharmacies will save an estimated $5.1 billion for consumers, employers, and other payers in 2015, and $59.6 billion over the 10-year period 2015-24.
- Specialty pharmacies will save an estimated $13.5 billion for consumers, employers, and other payers in 2015, and $251.5 billion over the 10-year period 2015-24.
- Combined, mail-service and specialty pharmacies will save an estimated $18.6 billion for consumers, employers, and other payers in 2015, and $311 billion over the 10-year period 2015-24.
State and federal laws and regulations that place restrictions on PBMs’ management of specialty pharmacies could substantially increase prescription drug costs, thus affecting patients, employers, and health plan sponsors. Legislation that restricts the use of these mail and specialty pharmacies could put these savings at risk.
Resources & References
- Specialty drugs and pharmacies, Report 355. National Center for Policy Analysis. May 22, 2014.
- Managing Specialty Medication Services Through a Specialty Pharmacy Program: The Case of Oral Renal Transplant Immunosuppressant Medications. Journal of Managed Care Pharmacy. January 2013.
- Fein, Adam J. The 2016 Economic Report on Retail, Mail, and Specialty Pharmacies. Drug Channels Institute. January 2016.
- Mail-Service and Specialty Pharmacies Will Save More than $300 Billion for Consumers, Employers, and Other Payers Over the Next 10 Years. Visante. 2014.
- Aetna: Condition Specific Support. Aetna Specialty Pharmacy. 2015.
- BriovaRx Pharmacy Services. BriovaRx. 2015.
- Cigna Specialty Pharmacy Services. Cigna. 2015.
- White Paper: The Management of Specialty Drugs. sPCMA. February 2016.