Understanding Prescription Pathways for Biologic Medication Therapy

Practices routinely encounter communications from pharmacy benefit managers in the form of medication prior authorizations and appeals. It’s important to understand that prior authorizations and appeals may or may not be directly managed by the pharmacy benefit manager. This is a common area of confusion. Finding out which organization and, specifically which department within the organization, is responsible for processing the communications will improve the success of treatment coverage.

In addition to being a third-party administrator of prescription drugs, a majority of pharmacy benefit managers own and operate specialty pharmacies.

Specialty pharmacies are all competing for access to patient lives in need of high-cost therapies to be dispensed. It is important to understand what avenue a specialty pharmacy takes to gain access to patient lives.

Some specialty pharmacies align with pharmacy benefit managers and insurers to enforce pharmacies align with pharmaceutical companies to provide data and expertise for specific therapies. Specialty pharmacies also align with providers to assist in navigating the complexities brought on by third parties and to utilize the pharmacist in direct and indirect care. They are also partnering with all three—pharmacy benefit management companies, pharmaceutical companies and providers.

Pharmaceutical companies contract with third-party hub service companies to administer patient access, reimbursement and maintenance therapy programs for their proprietary products. Common services provided are co-pay assistance, benefits investigation, free drug programs and patient support. Hub service com­panies can be standalone businesses or internal business units of pharmacy benefit man­agers, specialty pharmacies and internal components of the pharmaceutical companies.

Understanding the relationships and reputations of these third-party com­panies in your community will help practices implement strategic policies that improve your patient’s prescription journey, medication adherence and clinical outcomes.

Limited Distribution

Another factor affecting the prescription pathway is medications with limited distribution policies. Limited distribution is a strategy used by pharmaceutical companies to have more control of the supply chain. Typically, a limited distribution medication will be exclusively dispensed by one or a select number of specialty pharmacies chosen by the pharmaceutical company.

Knowledge Is Power

Understanding that there are several industries influencing the prescription pathway will help care team members navigate the complexities of the patient’s journey once a self-administered biologic or small-molecule medication is prescribed. Pharmacy benefit management companies, pharmaceutical companies and specialty pharmacies often overlap and serve multiple purposes. Find the best way to unravel the complexities for your patients.

Andrew Hochradel, PharmD, is the director of specialty pharmacy for Prescriptions Plus in West Allis, Wis.

Reference

1. Balto DA. The state of competition in the pharmacy benefits manager and pharmacy marketplaces. House Judiciary Subcommittee on Regulatory Reform, Commercial, and Antitrust Law. 2015 Nov 17. https://judiciary.house.gov/wp-content/uploads/2015/11/114-52-97631.pdf.