Best Practices for Specialty Pharmacy Referral and Intake

Optimizing workflow can enhance the specialty pharmacy patient experience.

Creating streamlined, efficient workflows that allow pharmacies to handle patient referrals optimizes patient care and increases productivity of specialty pharmacy operations.

While attempting to develop processes for the receipt, routing, and handling of prescription referrals, specialty pharmacies must consider the multiple stakeholders involved, and how to best engage each of them to facilitate patient onboarding. Many questions arise when developing processes for referral and intake of new patient prescriptions.

More specifically, what is the best way to refer a patient to a specialty pharmacy? At what point is patient and physician engagement necessary? How often should there be proactive outreach? What questions and data should be captured during the referral process?

Answers to these questions often are dependent upon the patient population receiving care, the disease state being treated, level of physician contact needed, and the types of data required to demonstrate outcomes and fulfill contractual obligations with payers and manufacturers.

Ultimately, the most important question is this:

What should the referral experience be for a patient requiring specialty pharmacy medication and services?

Initial Diagnosis

Specialty pharmacies must be empathetic to the fact that many patients for whom they receive referrals have frequently just been diagnosed with serious medical conditions, such as cancer, ultra-rare and life threatening orphan diseases, multiple sclerosis, and others. In many cases, these patients have just been told for the first time by their physicians that they have these conditions.

As anyone could imagine, these patients are overwhelmed and most likely find themselves searching the internet for information about their newly diagnosed condition. Specialty pharmacies, partnering with physician offices, can offer some clarity to patients about what to expect going forward.

By educating prescribers, specialty pharmacies can reinforce the importance of the prescriber informing the patient who a specialty pharmacy will be reaching out to them in the near future with updates about their prescription claim. The prescriber should indicate the name of the pharmacy where the medication was sent, and provide the pharmacy phone number to the patient if they have any additional questions.

Providing information to the patient prepares them to receive outreach from the specialty pharmacy, as well as providing a resource for patient information and education. Additionally, specialty pharmacies should strongly consider hiring provider relation liaisons.

Individuals working in this role will serve as a primary point-of-contact between a prescriber’s office and the specialty pharmacy. Building rapport through this model helps build relationships and trust between the specialty pharmacy and the referring physician’s office.

Data Entry and Benefits Investigation

Specialty medication orders differ from traditional medication orders because specialty orders are typically complex dosing regimens that require unique tapering, weight-based dosing, or special administration instructions. Therefore, the data entry process for specialty medications can become more complicated.

Creation-of-order templates assists prescribers in initiating therapy for their patients. They also help to ensure complete, accurate prescribing and reduce the frequency for specialty pharmacy outreach for prescription clarification.

Specialty pharmacies should work with manufacturers and physicians to develop templates for each specialty medication to facilitate prescribing. The templates should contain information such as the drug name, available strengths, and commonly used directions.

The template may also contain sections for ancillary supplies that the ordering physician would like to accompany the specialty medication, such as epinephrine, syringes, gauze pads, sterile saline, etc. In addition to assisting with prescribing, the templates can capture other information necessary for claims adjudication.

Sections that include the patient’s medical and pharmacy coverage greatly assist the specialty pharmacy in managing the referral.

Claim Adjudication/Authorization and Appeals Processes

Perhaps one of the greatest services provided by a specialty pharmacy is prior authorization support. Prior authorizations usually fall into one of three categories.

  • specialty pharmacy preparation of prior authorization, followed by physician review and physician submission
  • specialty pharmacy preparation and submission of prior authorization
  • physician submission of prior authorization

In all cases, the pharmacy can assist the prescriber with prior authorization support by providing the correct prior authorization forms, as well as informing the patient which next steps are being taken to initiate therapy for their condition. This interaction is crucial to helping the patient understand why there may be time between receipt of the referral and the start of therapy.

Specialty pharmacies can also support physicians by drafting statements of medical necessity or gathering clinical data from other care sites. Lastly, specialty pharmacies can bring together manufacturers and patients to speak directly with health plans to aid in coverage determinations.

Approval and Patient Onboarding

Once patients are approved to begin their therapies, specialty pharmacies are uniquely positioned to offer clinical services. During the introductory call to the patient, the clinical pharmacist has an opportunity to review the patient’s medication profile and perform a prospective DUR.

They can also offer patient education on the prescribed therapy, and set expectations for the patient’s treatment journey while on therapy. Building a strong foundation and understanding for the patient is critical to long-term adherence.

Role of HUB Services in Patient Care

The development and recent expansion of HUB services has revolutionized the referral and intake process. The scope of services provided by HUBs varies.

In some instances, HUBs work to collect data and distribute prescription volume to a network of pharmacies. Occasionally, HUBs offer an entire array of services, including benefits investigation and verification, as well as test adjudication for the dispensing pharmacy.

The key to a successful HUB is its ability to coordinate the delivery of care between the prescriptive and dispensing process. HUB services that collaboratively work with specialty pharmacies to initiate patient therapy will be the most successful.

Outlined above are several considerations to make when developing a referral and intake process for a specialty pharmacy. The ideal referral and intake process is one that proactively engages the patient at key junctures in the filling process.

Ultimately, specialty pharmacies can provide great value to patients and providers through use of efficient workflows, creation-of-order templates, and prior authorization support.

About the Author

Justin Smerker earned his PharmD degree from the University of Pittsburgh in 2009. He is currently a clinical pharmacist for PANTHERx Specialty Pharmacy. He has experience in the implementation and delivery of high-touch patient care services as well as in clinical management, persistency, and adherence programs. Justin also has participated in assisting with the successful launch of newly FDA approved medications. He has served as an adjunct clinical instructor for experiential education at Duquesne University. Prior to working in the specialty pharmacy sector, Justin successfully managed high volume retail pharmacies. Justin is currently enrolled in the Masters of Science in Pharmacy Business Administration at the University of Pittsburgh.