From insurance delays to injection concerns, pharmacists can help patients navigate the first month and avoid preventable treatment interruptions.
Arnold Hitoaliaj, PharmD, MBA, is a clinical pharmacist II at Yale New Haven Hospital, specializing in immunology, transplant, and rare diseases. His work includes specialty medication management, patient education, and interdisciplinary collaboration.
Letiana Hitoaliaj, PharmD, is an internal medicine clinical pharmacist at VA Connecticut Healthcare System. Her clinical interests include medication safety, evidence-based pharmacotherapy, and transitions of care.
No external funding was received. The authors report no conflicts of interest.
A patient is finally prescribed a biologic after months of uncontrolled symptoms. They leave the appointment feeling hopeful. Maybe this will be the medication that makes a difference. A week later, they call the pharmacy. “Has my medication been approved yet?” The prescription is still waiting on insurance. Once approved, it must be sent to a specialty pharmacy the patient has never heard of. Then comes another call about delivery, copay assistance, and scheduling the first dose.
What started as a hopeful moment has turned into a frustrating process. This is an illustrative scenario, but it is one that will sound familiar to anyone working in specialty pharmacy. We often focus on selecting the right treatment. Yet getting a patient started, and keeping them on therapy, can be just as challenging.
The first 30 days deserve more attention than they sometimes receive.1
A prescription may be approved, but that does not mean the patient is ready to start. Depending on the medication, there may be laboratory tests to complete, infection screening to review, or vaccinations to discuss. For certain immunosuppressive therapies, tuberculosis and hepatitis B screening are important considerations.2,3
Insurance adds another layer. A prior authorization may be approved, but the patient may still face a high copay or be required to use a different specialty pharmacy. These details can delay treatment.4
One of the most useful things pharmacists can do is check what is still outstanding before the first dose is scheduled. Has the patient completed the necessary screening? Is the medication covered? Does the patient know which pharmacy will contact them? Most importantly, do they actually have the medication?
Patients are often given a lot of information during their first visit. By the time they get home, they may remember only part of it. For someone starting an injectable biologic, even opening the package can feel intimidating. Patients may wonder whether the medication needs to warm to room temperature, where to inject it, or what to do if they make a mistake. They may not always ask.
Instead of ending counseling with “Any questions?” we have found it more useful to ask patients to explain how they plan to take their medication. For injectable therapies, reviewing the device together can uncover confusion that written instructions may not address.
Sometimes, a patient understands why they need the medication but has anxiety about giving themselves an injection. That concern deserves just as much attention as the clinical information.
A patient may start treatment without any problems and then develop concerns 1 or 2 weeks later. Perhaps they experienced an adverse effect (AE), they are worried because their symptoms have not improved, or they missed a dose and are unsure what to do next. These issues are easy to miss if the next conversation happens only when a refill is due. A brief follow-up call can tell us a lot.1
Start with a simple question: “How has everything been going since you started treatment?” It opens the door to a more useful conversation than asking only whether the patient is taking the medication. From there, we can ask about AEs, administration difficulties, missed doses, and any problems obtaining treatment.
We can also remind patients that improvement may take time. Depending on the medication and disease, a meaningful response may not be apparent during the first month. Patients should know what to expect so they do not become discouraged too early.
One issue that deserves more attention is the transition from loading to maintenance dosing. Many specialty medications have different schedules when treatment begins. A patient may receive several doses close together before moving to a less frequent maintenance schedule.
This can create confusion. For example, a patient may understand the first few injections but are unsure when the next dose is due. A prescription may also need clarification if the loading and maintenance instructions are not clearly documented. Before the patient finishes the initial dosing phase, pharmacists should confirm the next dose date, the correct maintenance regimen, and whether a new prescription or authorization is needed. A simple dosing calendar can be helpful. It takes little time to review, and it can prevent a missed dose or an administration error.
Not every patient will feel better after 30 days. Some medications take longer to produce a noticeable response. That does not mean the first month was unsuccessful.
At this stage, success may mean the patient has started treatment, understands how to take it, and feels comfortable reaching out when something goes wrong. Pharmacists should also confirm that the next refill is arranged and that no new access barriers have appeared. A patient who has taken every dose but cannot obtain the next refill is still at risk of a treatment interruption. These are the details that matter.1,4
Starting a specialty medication is rarely as simple as picking up a prescription. Patients are navigating insurance approvals, new pharmacies, unfamiliar devices, and the uncertainty of whether treatment will work. As pharmacists, we may not be able to eliminate every barrier, but we can make the process less overwhelming. Sometimes that means catching an authorization problem before the next dose is due. Other times, it means reviewing an injection technique or reassuring a patient who expected to feel better sooner. And sometimes, it is simply calling to ask how things are going.
The first 30 days are about more than getting medication into a patient’s hands. They are about helping patients feel supported enough to keep going.
