Summary NURS 251 Pharmacology Module 9

NURS 251 Pharmacology Module 9 Module 9 9.1 : Introduction to Specialty Medications In general, specialty medications are high cost medications used for treating complex disease states. They can be challenging to both manufacture and administer, and they often require significant patient education and close monitoring to ensure theirsafe and appropriate use. Although specialty medications were once a very small piece of the pharmaceutical industry, there has been a significant change over the last 20 years and especially within the last decade. Specialty medications are now the fastest growing segment of the pharmaceutical industry. Common characteristics associated with specialty medications are listed in Table 9.1. Table 9.1 Specialty Medication Characteristics High Cost Potential forlimited or exclusive availability for distribution Complex treatment regimen that require ongoing monitoring and patient education Treat rare diseases Special handling,storage, or delivery requirements Treat diseases known to have long term orsevere side effects or increased fatality Biologically derived and available in injection, infusion, or oral form Payers may define what they consider to be a specialty medication for reimbursement and contracting purposes. With the increase in specialty medications over the last two decades, a whole new approach to dispensing these medications emerged called specialty pharmacies. Generally, specialty medications are not available at typical community pharmacies, so patients must obtain them through specialty pharmacies. There are many reasons for this: some practical, some financial, and some clinical. Traditional retail pharmacy is not designed to handle these complex, costly medications. First, the high cost alone, in many cases, would prohibit retail pharmacies from stocking the medication. Second, the often-busy nature of a retail pharmacy does not align itself well with being able to appropriately manage and support the needs of patients with complex disease states. For these reasons, the first specialty pharmacies began in the early 2000s. Specialty pharmacies are typically required, through their contract with health insurance companies, to meet unique requirements that are not part of their contracts with retail pharmacies. Examples of these requirements are listing in Table 9.2. Table 9.2 Examples of Specialty Pharmacy Services Coordinating care and facilitating the drug access Case management- disease state management Facilitating mail order delivery logistics Product device training when applicable Working with health insurance to determine coverage and help coordinate any requirements of the insurance company Data management of technical and clinical patient care services. Investigating patient assistance programsfor patients without insurance or lack of coverage Call center development Patient Experience A patient receiving a prescription for a specialty medication should be aware that the process for getting the medication is going to look different than the normal retail pharmacy experience. However, the system is designed so that the patient hasthe best chance ofsuccessfully obtaining and using the medication safely and appropriately. The prescription would first be sent to the specialty pharmacy. The specialty pharmacy then takes responsibility for making sure the patient gets the medication, understands the risks and benefits, is able to afford it, able to take it appropriately, and will follow through with any necessary monitoring. The patient may be connected with a case manager that will call them on a monthly basisto make sure there are no issues with the medications, check to see if they had any required monitoring completed, provide any necessary education, and/or answer patient questions. Patient follow-up often happens every month prior to sending out the next months’ worth of medications in order to minimize waste, ensure safety, and assess for efficacy. As specialty pharmacies are generally not local to the patient they are caring for, care and coordination are often provided telephonically. The process is centralized, and the medications are shipped to the patient’s house or, in some cases, to the facility that will be administering the medications.