icon representing prescription medication

03 ― Specialty

While ePA for medication is quickly becoming more common, one area that has not yet reached its full potentiality is an electronic solution for all the elements required for specialty medications. As it stands, a patient may wait 3-6 weeks for treatment without a specialty solution.3

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04 - Real-Time Prescription Benefit

Defining Specialty

The industry has yet to create one definition for specialty medication; however, as a rule they are often classified as high-cost drugs (on average, a wholesale acquisition cost of more than $670) which are used to treat chronic, complex or rare diseases.4

Their complexity is exacerbated due to the fact that they normally require unique administration (i.e. nebulizer, injections) and more consistent patient monitoring by way of labs or regular checkups, and more time-intensive up-front processes, enrollment documentation, REMS and PA. All of these requirements must be taken care of before the patient ever gets their specialty medication.

By 2020, a projected 9 out of 10 top-selling drugs by revenue will be specialty.5

Completion Time

In today’s landscape, E-Prescribing can be challenging for providers due to the complexity of determining coverage and limited pharmacy distribution. The question is often asked if ePA can be used for a specialty medication, even when E-Prescribing does not offer the ideal solution. The answer is yes.

“The good news is that patients are being treated for rare and complex conditions and living healthier and happier lives.” — PBMI drug report6

Current Process

The current process of approval for specialty medication is extremely paper-heavy, similar to PA before the advent of ePA. Forty percent of providers cite PA around specialty medications as the main pain point when prescribing the drugs, and 30-50 percent of specialty PA request denials involve administrative error.7

Additionally, there is little transparency for the provider to know which specialty pharmacy is authorized to fill the prescribed specialty medication for a specific patient.

A streamlined workflow for specialty medication benefits all stakeholders including the pharmacy, provider, payer and most importantly, the patient. A solution that allows the ability to monitor treatment is critical.

Graph depicting four pain points (PA, Communication, Financial Assistance, and Time) for providers regrading specialty medication

Forty percent of providers cite PA around specialty medications as the main pain point when prescribing the drugs.8

An integrated workflow can be used to understand the timeliness of medication delivery for the patient (i.e. how long it took from the prescription process to the patient actually commencing therapy), adherence to their medication and how it impacted their health.

When a streamlined specialty solution is not incorporated into the provider workflow, a patient may wait 3-6 weeks for treatment.3

The seemingly endless cycle of communication and confusion with the provider, pharmacy and health plan puts the patient in danger of not receiving or adhering to this important medication.

Illustration depicting a calendar, prescription medication, and cobwebs

A patient may wait 3-6 weeks for treatment without a specialty solution.3

Ideal Workflow

The ideal workflow management tool will address gaps in communication and efficiently streamline and reduce back and forth between all stakeholders and provide more transparency on behalf of the patient. Providers should be able to identify which specialty pharmacies can service the patient (from a neutral perspective), select an appropriate network pharmacy and complete the steps necessary to coordinate and monitor treatment within their normal workflow.

Specialty pharmacies would then receive a complete set of clinical questions required to process the patient’s therapy. The solution should also provide personal support that encourages the submission of required information on the initial PA in an effort to prevent any unnecessary denials.

The top elements that specialty providers report they want to have in a specialty solution are as follows:8

90% - Complete a PA

76% - Determine which specialty pharmacy is in-network

66% - Determine the expected co-pay

62% - Complete an appeal when necessary

47% - Complete benefits investigation

A Closer Look

A provider faxes the specialty medication enrollment form to the specialty pharmacy they think can fill the script, but unsure if the preferred pharmacy is correct.

A provider selects the specialty medication they want to prescribe with full transparency into the available specialty pharmacy network.

The specialty pharmacy calls the provider to gather patient insurance and clinical information for the PA request, adding more time to the process.

The provider, once understanding where they can send the script, can initiate the prescription electronically, including the patient benefit info enrollment documentation and initiated PA.

The provider and specialty pharmacy exchange a series of phone calls and faxes to complete enrollment, benefits investigation and PA.

The provider reviews and submits PA to plan, completes E-Prescribing all in one streamlined workflow with no unnecessary back and forth.

The provider submits the PA to the plan. The plan reviews and makes a determination, but it’s not communicated to specialty pharmacy and provider.

The plan reviews and makes determination; the outcome is delivered electronically to provider and specialty pharmacy.

The specialty pharmacy and provider exchange more calls to communicate determination and fill the script. No dispense information is communicated.

The specialty pharmacy fills the medication for the patient and sends dispense information electronically back to the provider.

Providers Are Ready for an Enhanced Solution

"There is a larger burden for the ePA for a specialty medication."

― Barb Robison, Office Manager

Key Takeaway

Key Takeaway

In 2017, 300,000 NPIs submitted an ePA for specialty medication,9 indicating providers want to do these processes electronically. A PA can be submitted through web portals initiated at the pharmacy, or through a doctor’s EHR. Unfortunately, it does not yet account for the additional factors that prescribers care about such as enrollment forms and pharmacy visibility.

A pilot program is in progress to address these other barriers. CoverMyMeds is actively working to provide a solution that will be inclusive of all factors in the specialty prescribing process.