An ideal patient care model in specialty pharmacy involves several factors.
It is difficult to truly know how you will respond to a personal health care crisis or difficult diagnosis.
It is not something most of us think about, nor do we practice a response for hearing bad news. Some of us will control our emotions, appearing to take the conversation in stride. Meanwhile other people may have their minds start to race with questions, only partially listening to the information being presented.
Either way, after the initial wave of confusion passes and you are prescribed a specialty medication, what do you need to know about this medication, and how will the process to obtain the medication work? If you have an expectation based upon experiences from filling a prescription at a traditional retail pharmacy, or through a 90-day mail order pharmacy, then prepare for a new pharmacy experience.
Specialty pharmacy should be a high-touch, high-tech experience that supports a short-term treatment, or potential life-long medication therapy through disease-state specific programs and consistent two-way communication.
In a best case scenario, the prescriber electronically prescribes the specialty medication to either a HUB or to a specialty pharmacy in the patient’s prescription benefit network. Both of these choices would minimize any additional triages of the patient and prescription information to another specialty pharmacy.
Another beneficial piece of information provided by many prescribers informs the patient about the availability of the specialty medication, which helps set the expectation that a pharmacy other than their local retail pharmacy could be reaching out regarding the prescription.
Now you, as a newly diagnosed patient, start thinking about a game plan for your health. You say to yourself, “One more thing to add to the list, follow up on the prescription.” You scribble it down on a note pad.
Then you realize, “Who do I call?” The packet of information from the prescriber’s office might have a pharmacy name or telephone number, or maybe a call back to the office to ask the person who answers the phone, “What am I to do next?”
“Who do I call about the medicine?”
Before you can look for a telephone number or call the prescriber’s office, your phone rings, and it is the pharmacy the prescriber mentioned to you. If you were not able to take the call, a message would have informed you that a prescription was submitted by your prescriber, the pharmacy has it, and is beginning the benefit investigation to determine your best coverage options.
This initial communication alleviates some of the uncertainty about this new process, letting the patient know the prescription was received. The initial steps of being serviced by this pharmacy are underway, providing a key first step in specialty pharmacy.
There is a strong possibility that some additional information is needed to fully research all the coverage options available to you. Connecting with the pharmacy could be necessary to provide your prescription card, medical coverage information, secondary payor information, and some other elements needed to get a complete the demographic and insurance picture. This brief, initial conversation with the pharmacy gives you some peace, knowing there is work conducted on your behalf to get you the prescribed medication for treatment to begin.
The call with the pharmacy ends with a commitment to communicate with you, at least every 72-hours, to provide an update on the status of the prescription and benefit coverage. You are made aware of the likelihood that the medication will require an additional level of approval, which explains why it may take several days to gather and submit this information for review and approval.
In the event of a time-sensitive or urgent need to start the medication, all attempts are made to escalate through the insurance clearance process to meet the deadline. Overall, the initial call made from the pharmacy to the patient within 24 hours of receiving the prescription is an ideal timeline to follow.
Within a few days another contact is made by the pharmacy, the pharmacy benefits expert has finished the benefits investigation, and wants to confirm a good time to go over the findings. You confirm that now is a good time to discuss it, or you schedule a call back for another, more convenient time.
The pharmacy informs you of the prescription cost, any out-of-pocket amounts, deductibles, coinsurance, or copays related to the prescription. The benefit expert also shares any patient assistant programs available to you, based upon the drug manufacturer or other programs that help lower the cost of the drug or the copay costs.
The pharmacy knows it is essential to get you started on medication therapy, and that remaining on the therapy is vital to long-term, positive outcomes. Eliminating drug cost as a barrier to treatment from the outset can result in a strong patient and pharmacy relationship.
In the best scenarios, financial support is available, and it makes patient responsibility a manageable cost. The decision to begin treatment is agreed upon by the patient once the full understanding of the financial impact is considered.
In many cases, the decision is not just about the drug treatment for the physical ailment, but also the impact the cost of the drug can have on the family finances. The pharmacy continues the on-boarding process by confirming demographics, collecting alternate contact information, offering digital services for refill reminders and order status check-ins, a method of payment is put on file to cover the copay charges, and discussions on where the medication is to be delivered or picked up at the pharmacy are arranged.
This call can take some time, so the offer to set up another call to discuss the clinical aspects of the therapy with a pharmacist or nurse can be part of this call, or scheduled for another time. A clinical review and baseline of the patient’s health, prior to the first shipment, are important to set expectations of the therapy, including details about the medication, disease state, and plans to assess the efficacy of treatment are covered.
The choice is yours, as the patient, to decide when you have the time to dedicate to the calls, as the information and education about the medicine and health condition are critical to making an informed decision for your health, and a commitment to the process. The discussion with the pharmacist might seem to be overkill, as the prescriber is who you turn to with questions about this diagnosis.
Previous discussions covered the cost of the medication and your options for refills, delivery, and how to communicate with the pharmacy with questions. You soon learn that the high-touch service of specialty pharmacy is not just about insurance coverage, but includes the pharmacist who specializes in your disease state, offers suggestions about when to best dose the medication, what side effects to expect and when, what to do if you miss a dose or get an infection, storing the drug properly, traveling with the drug, how to dispose of any drug waste, and much more.
You are surprised to learn that certain side effects will not occur until you have been on the medication for 45 days or more, and the pharmacist will call you around that time to check in and offer additional ideas and support to manage those side effects. The pharmacist discusses taking over-the-counter medications and supplements, and asks that you keep the pharmacy informed if you add any new medications or products of this nature to your regimen.
You might be offered the services of a nurse to discuss self-injection or a dietician to help with meal planning or other self-care support. You soon realize the specialty pharmacy is offering a different level of support and interaction than you ever thought was available through a pharmacy.
You are almost through the on-boarding process, and the final steps are to agree upon a start date. The pharmacy will inform your physician of the plan, and to get the medication into your hands to begin taking it as prescribed.
You will be reminded about the refill process, so that you do not run out of medication. When refilling your prescription, you need to confirm with the pharmacy a few questions in order to kick off the refill process. Soon the order is ready, ensuring no lapse in therapy.
Once the initial dispense is in your hands, expect a 7-day follow up call to discuss your first week on therapy, review the materials that were included in the initial packaging, like a welcome kit explaining the “Patient’s Rights and Responsibility” information. This call also provides the pharmacy with another touch point to see if the self-injection is being done properly, following proper injection techniques.
The call that occurs a week after the start of therapy also reinforces the idea for the two-way communication between you and the specialty pharmacy. It provides the specialty pharmacy with the ability to verify the patient has all the tools needed to be successful, and remain compliant on the medication.
In a perfect world, this could all happen in a few days; however, the reality with prior authorizations and researching the financial options for drug coverage is a tedious and time consuming process. If it takes an average of 21-days from the date the prescription was written until it is dispensed, it can be tolerable, as long as there is consistent communication loop.
The most successful and respected specialty pharmacies focus on the on-boarding process, establishing the communication link between all parties, and maintaining it throughout the entire relationship with the patient and provider.
About the Author
Jill Schachte earned her B.S. in Pharmacy from Duquesne University and is currently enrolled in the Masters of Science in Pharmacy Business Administration (MSPBA) program at the University of Pittsburgh, a 12-month, executive-style graduate education program designed for working professionals striving to be tomorrow’s leaders in the business of medicines. Jill has spent the past 20 years working in specialty pharmacy, starting as a clinical pharmacist with Stadtlanders Pharmacy and working in a variety of a management roles in specialty pharmacy operations for CVS Health. Jill’s current role is on the CVS Specialty Professional Practice team with a focus on accreditation and compliance for all the specialty pharmacy locations within CVS Health.