Specialty Pharmacies Fill a Critical Role in Treating Complex Illness

Nora sat on the bench outside her doctor’s office to process the news she just received. She has cancer. Amid the devastating news, she heard a key phrase: It’s treatable. Part of the treatment includes medications that aren’t available through her usual pharmacy. Nora will need to use a specialty pharmacy to get her cancer treatment medications.
 

What is a Specialty Pharmacy?

Scientists, researchers, and medical professionals have achieved breakthroughs over the last several years in treating or curing chronic conditions, illnesses, and diseases. When these breakthroughs come in the form of complex, personalized medicines, a highly specialized team ensures the medications are taken in a way that the evidence shows they work best. This is the driving force behind a specialty pharmacy.

Most of the more than 4.75 billion prescriptions filled in retail pharmacies in 2022 were off-the-shelf medicines in standard dosages.

“Retail pharmacies are best used when a person needs medication to treat an infection or short-term condition,” said Dan Mandoli, president of specialty pharmacy at Elevance Health’s pharmacy benefit manager, CarelonRx.

Nora knew of several retail pharmacies in her area, but she was not familiar with any specialty pharmacies. She appreciated that her doctor gave her a list of them. Several of the specialty pharmacies are stand-alone stores, and two are part of hospitals in her area. While most retail pharmacies advertise directly to consumers in their area, specialty pharmacies work directly with and through care providers to reach their customers, which is most likely why she wasn’t familiar with them.
 

What is a Specialty Drug?

Specialty drugs are medications used to treat complex illnesses. They can treat health conditions such as cancer, hemophilia, rheumatoid arthritis, and cystic fibrosis. They can also help prevent rejection of an organ transplant.

Some specialty drugs can be taken by mouth. Others require a care provider to deliver them intravenously (by IV) or by injection. Specialty medications are often high cost, running more than $10,000 per treatment to well over $100,000 per year. In 2022, specialty medications accounted for 55% of the total drug spend in the United States.
 

What Should People Expect from a Specialty Pharmacy?

Nora soon learned that specialty pharmacies provide support that goes well beyond distributing specialty medications. Highly skilled pharmacists, nurses, and care providers who work in specialty pharmacies often have additional, advanced certifications and education.

“Specialty pharmacies provide a higher level of service, and this usually includes an evaluation by a specialty trained pharmacist, training for the patient on how to administer the medication (which could include instructions on how to inject a medication into the body), and significant time spent ensuring the patient can ask as many questions as needed so they feel comfortable taking their prescribed medication as directed,” Mandoli said.

Nora’s specialty pharmacy gave her intensive, individualized services including:

• Being available 24 hours a day, 7 days a week. A complex illness does not abide by business hours. Nora could reach someone at the specialty pharmacy at any time of day or night to discuss symptoms and side effects, address concerns, and get answers tailored to her experience. Being available around the clock allows the specialty pharmacy team to be hyper-responsive to their customers’ needs and changing conditions.
  
  
• Educational support. Nora did not ask many questions when she was diagnosed because she was so stunned. As she worked with the specialty pharmacy team, she grew more comfortable and asked questions during every phase of her treatment. Specialty pharmacies provide initial and ongoing education on the specialty drugs people receive. They work closely with people, monitoring them to detect any issues early so they can maintain safety for them and effectiveness of their treatment. Following and maintaining the medication schedule is crucial for treating people with complex illnesses, so the specialty pharmacy team works cooperatively to encourage adherence.
  
  
• Coordination with physicians. Nora had no idea how much work her specialty pharmacy team was doing on her behalf behind the scenes. Specialized team members assembled data from multiple sources and distilled it into a robust picture of her unique needs. The specialty pharmacy team is an important part of the care team, maintaining close communication with other care providers. They work cooperatively to administer the specialty medications best suited to their customers to achieve the best outcomes possible.
  
  “Specialty pharmacists coordinate dose modifications with the prescriber, monitor the patient’s lab results and symptoms, and continue to customize the specialty medications for each individual,” Mandoli said. “They can recommend ways to mitigate side effects or change doses if a patient isn’t reacting well to their current dose.”
  
  
• Administrative help. Removing administrative burdens allowed Nora to focus on her health. Her specialty pharmacy team completed administrative duties like securing prior authorizations and identifying benefits coverage from health plans. They even identified financial resources to help Nora offset the cost of her specialty medications as she moved into the more expensive phases of her treatment plan.
  
  “While financial assistance will vary depending on the type of health plan, it’s worth it for patients to ask whether there is help available, such as a lower copay,” Mandoli said
   

“Specialty pharmacies are essential in helping people navigate the rapidly evolving landscape of specialty medications, which continue to expand to treat a range of complex illnesses,” Mandoli said. “These pharmacies work to lower costs of these often high-cost therapies and increase access for people to healthcare professionals to promote adherence and safety. But most importantly, they are a 24/7 support system for people trying to manage their most complex illnesses and conditions.”