During the Educational Pharmacist Training (EPT), we delve into the intricacies of reading prescriptions and dispensing medications. It's disheartening when obstacles hinder us from fulfilling our primary goal – providing patients with their prescriptions promptly. In the realm of Specialty Pharmacy, achieving coverage for these prescriptions by insurance after the first attempt is a rarity. Achieving coverage at a cost manageable for the average patient requires a collaborative effort from pharmacists, pharmacy technicians, nurses, patient care coordinators, and other support staff. Let's explore why so much effort is invested in this process.

Understanding Cost Dynamics: One out of five U.S. adults struggles to afford their prescription medications. specialty medications, designed to treat complex disease - come with a hefty price tag. The Centers for Medicare and Medicaid Services (CMS) categorize a specialty medication as one with a minimum monthly cost of $830 for 2023. Despite being used by only 2.5% of all patients, specialty drug spending is projected to reach $311 billion this year, targeting diseases such as psoriasis, inflammatory conditions, oncology, multiple sclerosis, and more.

Factors Behind Specialty Medication Costs: Out of nearly 7,000 medications in development, 75% are specialty drugs. Innovation and the production of novel treatment options contribute to high drug prices. Manufacturers set high prices for specialty drugs as patents expire, often facing little competition from generic alternatives. Dispensing these medications involves substantial efforts, including work by pharmacists, pharmacy technicians, clinical nurses, or other staff members to ensure insurance coverage and affordability for the patient.

Challenges with Insurance Companies: Many specialty medications are not covered by insurance and may be excluded from formularies. Patients may be required to try less expensive alternatives before receiving coverage for certain prescriptions. Some insurance plans dictate specific pharmacies for filling specialty prescriptions. Without insurance or financial aid, most patients cannot afford these prescriptions. In case of initial rejection, pharmacy teams collaborate with physicians to file a prior authorization, a health plan requirement to prove the medical necessity of a particular medication. Insurance denials may still occur, leading to appeals filed by pharmacies and prescribers.

Strategies Employed by Pharmacies: Pharmaceutical manufacturers recognize that patient affordability and pharmacy pull-throughs are crucial to their brand's success. Over 30% of first prescription fills end in prescription abandonment due to "sticker shock." Manufacturers addressing this issue directly can reap significant benefits. Copay assistance programs from manufacturers provide financial aid to insured patients, reducing out-of-pocket expenses. Patient support programs offer education and adherence outreach, supporting patients in overcoming access barriers. Free drug programs through manufacturers also provide access to medications for uninsured or indigent individuals at no cost. Specialty pharmacy teams conduct benefit investigations, and when insurance and manufacturer contributions don't suffice, additional help from funding organizations ensures patients can access essential specialty treatment options.

In conclusion, Specialty medications are expensive and often unaffordable for the average patient. With the rapidly evolving field of medicine, specialty prescriptions will become more prevalent in treating complex diseases. Pharmacies will continue to work closely with prescribers, insurance companies, manufacturers, and alternative funding organizations to ensure patients have access to beneficial specialty treatment options for optimal health outcomes.

Kelly Malkamaki                  

RPh, Senior Product Pharmacy Analyst