When you have cancer, you may need to work with a specialty pharmacy to obtain your treatment drugs. This will probably be an experience you’re not accustomed to. According to the American Pharmacists Association, these elusive specialty pharmacies offer “high cost, high touch medication therapy for patients with complex disease states [like cancer]. Medications in specialty pharmacy range from oral to cutting edge injectable and biologic products.”
Specialty medications often have special storage or handling requirements, such as needing to be refrigerated. They may also need close monitoring by a pharmacist and ongoing clinical management from your care team. And, most annoyingly, these drugs are often unavailable from retail pharmacies. Here are a few tips to help you get the medications you need when dealing with these new providers.
1. Know Whether You Can Fill Your Prescription at a Regular Pharmacy
Your specific health plan will determine whether or not you must use a participating specialty pharmacy. If you choose to use a regular pharmacy but your plan requires you to use a specialty one, you’ll have to use out-of-network benefits or pay out-of-pocket. Other medications related to your cancer treatment, like anti-nausea and pain-relieving drugs, will probably still come from your regular pharmacy.
2. Know Whether Your Insurance Plan Must Approve Specialty Medications
Many health plans must give prior authorization before a specialty drug can be dispensed. Specialty pharmacies will typically work with your health insurance company to obtain prior authorization so the drug will be covered by your health plan if at all possible. This means they will act as a go-between for your doctor and the insurance company to complete whatever paperwork your health plan requires. And, in some cases, they may be able to suggest a different treatment that satisfies both your doctor and the insurance company.
3. Understand Your Insurance Coverage
Specialty medications are typically covered under both medical and pharmacy benefits. In general, medications you receive in a physician office or infusion center are covered under your medical benefits. Medications you take on your own are usually covered by your pharmacy benefits. In these instances, you’ll need to pay the co-pay upfront when you receive the drug.
4. Know Who to Talk to If Problems Arise
If you learn your specialty prescription has been denied, start by contacting both the specialty pharmacy and your insurance carrier to find out why. Specialty pharmacies generally pride themselves on their customer service as they expect patients to have questions and need support due to the complicated nature of cancer drugs. Don’t be shy about tapping into their expertise to ask them to work on your behalf. You can also ask to speak to a supervisor and/or a patient case manager at the pharmacy if needed.
5. Request Financial Assistance If Needed
Most drug manufacturers offer a co-pay assistance program to people in need. Your doctor or specialty pharmacy should be able to help you with this application.
Additionally, the specialty pharmacy may be able to assist you with applying to foundations or special-interest organizations for help paying for your specialty medication. The type of cancer you have may determine the organizations willing to help, but start with groups that focus on your disease. These organizations include the Leukemia & Lymphoma Society, Partnership for Prescription Assistance and the HealthWell Foundation.
Your pharmacy, specialty or not, is an important part of the oncology team. Use their expertise to get the medications you need as quickly and easily as possible.
The cost of treatment can make getting better seem impossible. UVA Cancer Center has financial resources available to address your concerns.Learn More