Medically Integrated Pharmacies: The Role of Limited Distribution Networks in Advancing Modern Oncology Pharmacy

As oncology care grows increasingly complex, ensuring equitable and timely access to high-cost, high-touch cancer therapies remains a pressing challenge—particularly in rural and underserved communities. In this interview, Pharmacy Times speaks with Jonas Congelli, RPh, associate executive director at National Community Oncology Dispensing Association (NCODA), about the critical role that limited distribution networks (LDNs) and medically integrated pharmacies play in supporting patient-centered oncology care. Congelli moderated the session “Beyond Limits: Rethinking Limited Distribution Networks in Oncology & Their Impact on Access & Care” at the NCODA Spring Forum in Denver, Colorado.

Congelli outlines how direct access to clinical information, streamlined prior authorization processes, and on-site dispensing capabilities empower oncology pharmacists to provide more personalized, efficient, and comprehensive care—while also navigating systemic barriers posed by pharmacy benefit managers (PBMs) and fragmented mail-order systems. Congelli also discusses how redefining distribution models may ultimately support better outcomes, continuity of care, and health equity for patients with cancer.

Pharmacy Times: How do LDNs impact patient access to oncology therapies, particularly in rural or underserved areas?

Jonas Congelli, RPh: We know that they greatly increase access to medications, especially those within a rural or underserved area. If you compare and contrast medically integrated pharmacy vs traditional pharmacy model, the medically integrated pharmacy—because they have direct access to not only the patient's medical record, the physician, the care team, and most importantly, the patient—that medication can get into the patient's hands much quicker than the traditional pharmacy system.

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Typically, these medications are high cost, high touch, and as such, they would have to go through a mail order specialty pharmacy in order for the patient to receive them vs the traditional retail pharmacy. Because of that, there's a lot of steps along the way where the delay can happen and occur with that patient care journey, starting off with the prior authorization. The medically integrated pharmacy can do the prior authorization. They have direct access to all of the information that is required for prior authorization. The mail order pharmacy can't do that. They have to when they get that prescription. They oftentimes reach out to the practice, and the practice is the one that has to provide and do the prior authorization process.

Financial assistance—oftentimes the mail order pharmacy doesn't have enough information to do detailed financial assistance for the patient, whereas the medically integrated pharmacy does have that access. And most importantly, as I mentioned before, they do have direct access to the patient, and then just access to the to the medication. Oftentimes the medication is on site, it's in stock, and can be dispensed in in a manner that is convenient to the patient, contrasting that to the mail order pharmacy. Whereas, even myself, I mean, I live in a very rural setting, just getting things mailed to our house is difficult. Oftentimes, it can take an additional day or two before we get packages sent and then also, when you look at underserved areas, where it may be more urban, there can be challenges there, where is that medication going to be left? Where is it going to be sitting for the patient to pick it up? Is there a signature going to be required for that pickup as well? So, there's a lot of hurdles that go into the mail order pharmacy system vs the medically integrated pharmacy system when it comes to access to these medications,

Pharmacy Times: How do LDNs affect oncology pharmacists' ability to provide comprehensive patient care and medication management?

Congelli: When you take a step back and you look at how medications are dispensed in this country, and you look at and contrast the retail pharmacy model, and that consists of, also the mail order specialty pharmacy model, to the medically integrated pharmacy model, if you had to design a system where everybody was accountable for the care of the patient, hands down that medically integrated pharmacy system is going to be able to provide the best care to the patient. If there weren’t any financial entanglements or anything along those lines that you often see and why prescriptions are often pushed to a mail order pharmacy system, you would agree that a medically integrated pharmacy system is the best system, and the reasons why is access. It's access to the information, it's access to the patient, it's access to the oncologist, it's access to the team itself, and when you have that information, you can do that deeper dive in the care of the patient. Traditional pharmacy model consists of the physician writing the prescription and then the pharmacist filling that prescription. And whatever information that you can get from that transaction is very limited. Oftentimes, the only thing that you can really do is maybe drug contraindications or things along those lines. Compare that to the medically integrated pharmacy where you have access to all of the information. You have access to the patient's labs, their pathology, their imaging, the office notes, anything that is going on with a patient, so you can do a much more comprehensive review of the therapy and make sure that therapy is appropriate for the patient, especially when it comes to the correct dose, the correct frequency, all of those types of things that a pharmacist in a medically integrated pharmacy can actually do and perform.

It's not uncommon, in a lot of these medically integrated pharmacies that that do have accreditation, whether it's URAC, ACHC, or the NCODA accreditation, we'll actually create a pharmacy treatment plan specific for the patient in detailed information that does provide additional education to the patient.

So, if you're comparing systems and models compared to each other, and again, if you didn't have a financial interest in either one of those models, you would hands down pick the medically integrated pharmacy model. I think it's a great opportunity for pharmacists, especially pharmacists to work to the top of their license to work with other professionals, especially in the oncology space, to be able to provide top aligned treatment to patients, comprehensive treatment to our patients, and, most importantly, safe and effective treatment for our patients, being able to monitor them not only for toxicity, but for educational gaps, for continuity, for all of those things that are important to keeping a patient on care as far as long as they can.

Pharmacy Times: What strategies can be used to balance the need for LDNs with ensuring timely and equitable access to life-saving cancer treatments?

Congelli: So, I think the most important is being able to have access to the medications, right if we don't have access to the medications, then we can't provide the care to the patients. Again, if you look at the system holistically, and you looked at it, and everybody had access to the medications, and everything was equal, that the patient had the choice where to receive their therapy, and they didn't get steered to one pharmacy or the other, it wouldn't matter what the distribution really looked like, because then it would be up to the patient where they want to receive their medication. But because we're in this area, where there's large entities that control where the prescription is actually going to go, speaking specifically about the pharmacy benefit managers and those that actually own their own mail order pharmacies. When we look at that, that is really where we start to see the system kind of fall apart a little bit, and where we don't have that ability to provide that continuity of care to our patients, and that's why we have to look at other ways to do this. [LDNs are] one of those ways where we have the ability to be able to take care of our patients without that fragmentation of care.

So just to kind of provide a little context, what are we talking about? As far as [LDNs], really, what we're talking about is a distribution network where access is provided to practices that practice medically integrated pharmacy. That could be a community oncology setting, it could be a hospital setting, wherever they're treating patients in oncology in a medically integrated pharmacy way. Then what they do is they also limit access to those PBMs and their mail order pharmacies. And by doing that, we've seen our ability to be able to take care of patients inside of the clinic, inside of the practice, increase tremendously. If you if you look at the ability to increase your capture rate and your ability to take care of patients in the medically integrated pharmacy network, it increases to almost upper 90s. When you look at the data, it's right around like 98% of prescriptions are able to be filled and captured inside a medically integrated pharmacy system.

Contrast that to an open system, where almost half of the prescriptions are going to have to be set out to a mail order pharmacy. And so, you could see those huge differences that can occur. Whether you're talking about an open or a limited distribution network. And again, I understand that when you talk about some of these terms, open can sound good, limited can sound somewhat negative. But when it comes to oncology and being able to take care of oncology practices, limited actually is good, and open is actually bad, if that makes any sense.

Pharmacy Times: How do LDNs influence drug pricing, reimbursement, and financial toxicity for patients with cancer?

Congelli: There's really no difference in reimbursement, there's no difference in toxicity, there's [nothing] as far as financial toxicity. We haven't found any differences between whether a drug is open going through an open distribution or limited distribution network on there. As I mentioned before, when you're going through prior authorization, it's still the same process, whether a practice is able to fill it or not. They're still having to do those same functions as whether they can fill it or whether they're going to have to send it out. So, there's no difference there.

Patient assistance is another thing, and again, trying to find patient assistance for patients, it doesn't matter whether the drug is something that you're going to be able to fill inside of the practice, or if it's going to be something that is sent to a mail order pharmacy, the practice is still going to have to look and find financial assistance for the patient. When I was at a practice, our goal was to have the patient pay as little out of pocket as possible. Our goal was really $0 again, and that's accessing copay assistance, that's accessing foundation assistance, doing whatever it is that we could do to limit the financial toxicity for our patients.

So, when you're looking at that and comparing, there really is no difference whether the medication is filled inside of the practice or if it's filled inside of a mail order pharmacy.

Pharmacy Times: What role do specialty pharmacies play in managing oncology drugs within LDNs, and how does this impact hospital and health system pharmacies?

Congelli: What does specialty pharmacy really mean? It's trying to understand what the true definition of specialty pharmacy is, and there’s probably many different definitions, depending on how you're approaching it.

So, my intention is never to bash anyone or to isolate or speak negatively of anyone, but if we're talking what a specialty pharmacy is, I would argue that medically integrated pharmacy inside an oncology practice or network is really a true specialty pharmacy, because their focus is solely on taking care of oncology patients. If we look at a specialty pharmacy in the context of the larger mail order specialty pharmacies, their specialty pharmacies in the context that they look at every specialty that currently exists, and oncology is the subset of all of those different specialties that they cover. So, I think that's a great differentiating point between the two in that a true specialty pharmacy is one that functions and focuses only on one disease vs a specialty pharmacy that may focus on multiple. What is that saying? Jack of all trades, but master of none? I think it's kind of probably applies a little bit to this, and that you could be a mail order specialty pharmacy and provide access to all of those different specialties, whether it's neurology or gastrointestinal or you name it, and then having oncology being another piece of that your knowledge depth is spread out over across all of those different specialties, so you have a familiarity with everything. But how deep is your knowledge depth go on to that, whereas a medically integrated pharmacy in an oncology practice setting, you're only focusing on oncology. So, your knowledge goes from something like this, to now, it's very deep. I think that's the biggest difference when you're comparing and contrasting specialty pharmacies into medically integrated pharmacies.

Pharmacy Times: What are the potential risks of supply chain disruptions within LDNs, and how can health systems mitigate these risks?

Congelli: Yeah, tariffs, I think we're still waiting to see what's going to shake out of the whole tariff discussion, whether drugs are going to get caught up into that and so we'll have to wait and see on that. Shortages are a real issue. The shortages are not limited to any sort of distribution strategy or network. Shortages are occurring in where we've seen the most commonly in oncology, and probably generally across the whole pharmacy system, is we're seeing them in the generic space. In oncology, last year was especially tough with a cisplatin and carboplatin drug shortages where we were managing day to day patients and their therapies, and we continue to see that it the shortages that are occurring in the generic space. Branded products, much less so. Again, there's a lot more control with a branded product, as far as manufacturing. But the generics are—we’re extremely vulnerable to generic shortages, and we're just constantly—when I was in a practice, I mean, we have one person that their job, or a good significant portion of their job, is to manage shortages, to manage purchasing and supply as well inside of the practice and make sure that we have adequate product on hand to treat our patients. This is a serious issue, the drug shortages, and probably would be appropriate for another topic at another time, because we could go on and on about the drug shortage issue in this country.

Pharmacy Times: How do LDNs impact clinical trial enrollment and real-world evidence collection for emerging oncology therapies?

Congelli: I don't think that there's really any changes there. The distribution doesn't really affect clinical trial enrollment that's going to be done at either a cooperative group level or a pharmaceutical manufacturer level when it comes to clinical trials, and the same thing with real world evidence. That is being collected on a macro scale that operates independently whether the distribution is open or limited.

Pharmacy Times: What best practices can be adopted to ensure that LDNs do not create unnecessary barriers to patient-centered oncology care?

Congelli: So that's what the really the focus of our session at the upcoming NCODA Spring Forum is going to be about, and our goal is to create new definitions of what is limited distribution and how we should be talking about it, especially in an oncology setting. Then I really want to make that clear is we're creating new definitions for limited distribution for the oncology setting. We're going to be rolling out those new definitions at the Spring Forum that is coming up, actually starting on Wednesday of this week.

So, stay tuned. We'll be rolling those out and again, it's all in alignment with doing what is best for our patients [with cancer]. And that's really the goal for all of this, whether it's new definitions for distribution, supporting the medically integrated pharmacy, all of that is to keep the patients at the center of everything that we do. And that's really the goal, my goal that's NCODA’s goal, and that should be the goal with everybody that's involved in health care.