Jessica Wapner

Specialty pharmacies have been a health care staple for years. These drug  outlets distribute high-cost medications, those requiring special handling, and  other drugs whose requirements often fall outside the capability of typical  retail pharmacies.

Specialty pharmacies began as private, mainly mail-order  companies, and many national drugstore chains now include their own specialty  component. But only recently have specialty pharmacies become integrated into  cancer care. A recent Drug Trend Report released by Express Scripts, a pharmacy  benefits manager, estimated that so-called specialty drugs for illnesses  including cancer, multiple sclerosis, and HIV will comprise 26 percent of drug  spending by 2010.

The rise of specialty pharmacies in cancer care is directly  related to the heightened availability of at-home treatments. The Food and Drug  Administration has approved oral cancer drugs for more than 40 indications  (includes drugs approved for more than one indication), and many of those  approvals occurred in the past decade. Up to 35 percent of cancer drugs in  development are for oral formulations, according to experts, while  self-injectable medications are also increasingly common.

Insurance providers are attracted to specialty pharmacies because  they offer helpful services for patients taking therapies at home, and, because  these companies have fewer overhead expenses since most are mail-order, their  prescriptions often cost less for the insurer. (Some specialty pharmacies have  physical locations in large cities, while others ship medications directly to  patients’ homes.)

But like the drugs they sell, specialty pharmacies come with their  own profile of benefits and side effects. Awareness of these has become a  necessity for patients.

Employing a program called medication therapy management, or MTM,  specialty pharmacies act as surrogate health care professionals. “[MTM is] a  proactive intervention program with the patient,” explains David Reese, vice  president of OncologyRX Care Advantage, a specialty pharmacy launched by US  Oncology, a health care services network. “We are trying to mimic what has been  occurring in the physician’s office.”

With MTM programs, oncology nurses and pharmacists educate  patients about how to take the drug and what side effects to expect, call  patients weekly for the first month or two of treatment, and operate a 24-hour  telephone hotline. Also, they will alert the doctor at the first sign of a  severe toxicity.

Patients also receive phone calls a week before the current bottle  of pills is due to finish to ensure timely refills, and the next prescription is  delivered to the patient’s doorstep. In addition, specialty pharmacies can often  help patients secure co-pay or other financial assistance.

But the use of specialty pharmacies in cancer care can be fraught  with problems. Delays at the start of treatment are common because insurers may  require patients to fill prescriptions through a specialty pharmacy, eliminating  conventional retail outlets from the treatment equation altogether. That  requirement is not always clear at the outset of treatment, so patients should  ask their insurance provider if using a specialty pharmacy is part of their  plan.

Patients and doctors often don’t know if a specialty pharmacy will  be required by the patient’s insurance company, says Joseph Muscato, MD, an  oncologist with Missouri Cancer Associates who has dealt extensively with  specialty pharmacies. But obtaining the necessary prior authorization and then  waiting for the medicine to be shipped can delay initial treatments for up to a  week, Muscato notes.

Specialty outlets sometimes require patients to receive up to 90  days’ worth of a drug at once. But cancer treatment regimens can undergo  frequent changes, possibly resulting in wasted pills, hours on the phone to have  alterations approved and processed, and unexpected delays in the next cycle of  treatment.

Plus, delivering drugs by mail is risky. Muscato recalls one  patient whose kidney cancer started progressing unexpectedly. After some  investigation, her medication, which required cool storage, had gone bad in the  summer heat, having been left on the porch in her absence.

Reese says OncologyRx Care Advantage requires a signature for all  prescription deliveries. As for the delays, many of these are “a factor of the  system,” he says, part of the unavoidable health care system red tape. Seeking  financial assistance can also delay the process, says Reese.

With oral drugs on the rise, specialty pharmacies are an  increasing presence in cancer care. Learning the ups and downs of this change is  essential to avoid the pitfalls and find benefit from useful services.

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