Contracting with Specialty Pharmacies

Contracting with Specialty Pharmacies

Today’s specialty pharmacies are more sophisticated, mature and valued for their services than in the past.  The most common services offered include:

  • Comprehensive patient management
  • Direct distribution of drugs to patients or physicians
  • Coordination of reimbursement and eligibility
  • All day access to a health care professional
  • Ensuring appropriate utilization of drugs

Carving out specialty pharmacy distribution and/or clinical services through a direct contract has the benefit of reducing middleman costs to the plan. This also requires the vendors to “earn the business” because if a member or provider is not satisfied with the services of one, they can switch to another. It also provides knowledge in setting rates because there are two vendors to compare against.

PBMs with in-house specialty pharmacies typically require (or incent) their clients to use their specialty pharmacy exclusively.  For employers, as long as the PBM has processes in place to coordinate the receipt by the patient of limited distribution drugs, the clinical services are sufficient and the rates have been analyzed and found to be market competitive, then exclusive specialty pharmacy arrangements should be considered.

Plan sponsors need to be prepared to pay for pharmacist services when seeking net cost or fully transparent contracts direct with any pharmacy.  Employers should identify opportunities for value and optimizing the performance of their benefit plan by using contracting strategies that are more forward-thinking. Examples include real-time and POS net cost claims information sharing, advanced clinical solutions for patients and medical and pharmacy care collaboration.  

Key service conditions and/or clinical services

At a minimum, the specialty pharmacy chosen should provide the following:

  • Competitive net cost from AWP discounts or other direct and transparent disclosures of negotiated discounts in the supply chain
  • Contracts with local pharmacies to provide emergency supplies or replace lost packages
  • Mailing services through a national mailing company or small courier service that are guaranteed to cover entire service areas and tracking services for packages
  • 24-hour access to nurses or pharmacists to answer member questions including support for patient assistance programs
  • Member education that demonstrates proper injection techniques, identifies ways to lessen adverse effects from different drugs and provides information on optimal therapies for specific diseases
  • Refill calls where the patient is contacted directly and refill necessity is addressed before the next prescription is filled
  • Strategies for supplying orphan drugs or those drugs with FDA distribution limitations
  • Solid clinical programs that are shown to improve outcomes
  • Prior authorization services with criteria reviewed by practicing providers that follow evidence-based guidelines
  • A comprehensive process for transferring the prescription from the retail pharmacy to the specialty vendor.  This includes calling the prescriber and member to inform them of the dispensing process and educating them about the components of the program.
  • A provider management department that will make face-to-face calls to providers explaining their services.
  • Superior reporting and data collection specific to groups, individuals and providers
  • Provide performance guarantees relative to their services, including shared risk arrangements.
  • Ability to separate billing for drug acquisition and dispensing costs, and clinical services using appropriate coding in claims