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Pharmaceutical Manufacturer & Payor Expectations When Partnering with a Specialty Pharmacy

When a pharmaceutical manufacturer or a payor is choosing a specialty pharmacy partner, there are many important aspects to consider and expectations they should have in the selection process. They want an experienced specialty pharmacy that has developed close working relationships with health plans and pharmacy benefit managers (PBMs) and has active network agreements in place with the ability to easily implement addendums to current payor/PBM contracts. For those smaller payor accounts that may not be in the active payor network of a specialty pharmacy, they want a specialty pharmacy to be flexible enough to offer a limited distribution letter from the manufacturer to obtain a letter of agreement (LOA) or single case agreement (SCA) to expedite the immediate needs of the patient with the intent of ultimately obtaining a therapy level agreement with the payor.

Payors and pharmaceutical manufacturers want a specialty pharmacy that understands the specific payor benefit designs, prior authorization processes, and utilization management strategies. The ability to navigate healthcare providers and assist them with prior authorizations, the appeals process, and letters of medical necessity is paramount for a specialty pharmacy. An effective specialty pharmacy has extensive coverage across the country not only in commercial plans, but also in government plans including Medicare Part D, Medicare Advantage plans, and Medicaid. It is critical that the specialty pharmacy has considerable expertise in billing under the medical benefit, but also the finesse to discern out what is best for the patient financially. The specialty pharmacy’s ability to bill a prescription under the medical or pharmacy benefit can substantially impact the patient’s decision to initiate therapy. In a recent manufacturer survey regarding specialty pharmacy, 33% indicated access to payors and payor relationships as the leading reason when asked, “What are the top reasons you chose the specialty pharmacy partners in your network?”

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In the same survey, manufacturers were asked, ”How Can the Specialty Pharmacies in Your Current Limited Distribution Network Improve?” More than half of the respondents indicated a desire for enhancement of services across the board, including in the areas of communication, responsiveness, data services, flexibility, and reporting. To expand on these enhancements, let us review them first from a clinical services perspective.

When choosing a specialty pharmacy, it is critical that the specialty pharmacy can meet your specific needs clinically by having an experienced clinical care team tailored to your therapeutic area. Typically, there will be a single point-of-contact, a program manager, that will orchestrate the clinical care team. With a dedicated single-point-of-contact, the referral process, medication delivery, and follow-up will be streamlined, thus enhancing communications. The 24/7 clinical care team is generally made up of nurses, pharmacists, and technicians who are empathetic towards the patient and caregiver(s) and have the expertise, training, and education to handle every clinical concern. Some specialty pharmacies have raised the bar by incorporating a nursing network across the country to provide nursing services (infusions, injections, etc.) in a home setting, especially in rural areas. This nurse network creates a sense of stability and an increase in adherence for many patients by receiving the compassionate care needed during scheduled treatments. While the nurses are there administering treatment, patient vital signs are taken and reported to the healthcare provider. Again, the nursing staff is communicating that the treatment was successfully administered and the next scheduled administration has been booked. As you can see, there are many factors for pharmaceutical manufacturers and payors to consider when choosing their specialty pharmacy partner.

In our recent guide, Rare Diseases, Gene, and Cell Therapies: Specialty Pharmacy Considerations, we cover what is most important when selecting a specialty pharmacy to partner with for your next drug launch. Download your digital copy of the rare disease guide. If you have immediate questions, you can also connect with an Orsini representative at any time.

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