I am seeing more and more drugs that are being moved from traditional retail status, meaning that you can get them from your local pharmacy, to specialty-drug status, available only from a designated pharmacy. According to Specialty Pharmacy Times:
specialty drugs or pharmaceuticals usually require specialty handling, administration, unique inventory management, a high level of patient monitoring, and more intense support than conventional therapies.
If one accepts the definition above, cost alone should not be enough to limit the product’s availability in the retail sector. However, the assignment of specialty status appears increasingly arbitrary, regularly focusing on drug cost. The arbitrary nature of the specialty moniker is most apparent when comparing different insurance plans. The same drug can be considered specialty in one plan, but not special in another.
Tales from the Counter
The state of Iowa recently switched its Medicaid recipients from a fee-for-service program to a for-profit managed care model. Originally, these plans were not going to be allowed to limit mediations to specialty status, but this stipulation was dropped in the 11th hour before implementation. It took less than 24 hours for one of our patients to be affected by this change.
One of our Medicaid patients has been receiving Invega Sustenna from our pharmacy. This patient was switched to one of the three MCOs now managing our Medicaid population. Like many of our patients receiving medications by intramuscular injection, our pharmacy actually administers the medication to the patient. The prescribers in our area, for a variety of reasons, often do not want administer medications in their offices. These practitioners rely on us to administer the medication. We order the medication, schedule the administration appointment, and administer the injection.
On April 1st, however, the new MCO returned a rejection for the Invega Sustenna. They require that the medication be filled at a specialty pharmacy. Going back to the definition above, the medication exhibits few, if any of the attributes listed. Cost alone appears to be the primary consideration.
A call to the MCO simply confirmed that they required the medication to be filled at a specialty pharmacy. When asked what was special about this medication, they replied that it was an injection. That answer did not impress me; I dispense a lot of not-very-special medications that just happen to be in an injectable form. When asked how they can provide the medication in a timely fashion, they offered to overnight ship it to the patient. I asked the MCO who was going to give the medication. They told me the patient would self-administer it or that a doctor would give it in their office. It is at this point I broke the bad news to the MCO representative: giving oneself a deep IM injection is not something most want to do, and the prescriber doesn’t give these injections in their office. I informed him that our pharmacy gives the injection to the patient.
After spending some time explaining these realities to the plan, I was able to secure a one time override for the medication because the injection was already scheduled and due to be given. This bought the patient some time, but it does not solve the problem. The medication is still arbitrarily designated as specialty-only. The plan, after learning that our pharmacy both provides and administers Invega Sestina to nearly a dozen similar patients, promised to follow-up and offer us a specialty pharmacy contract. I am not holding my breath. I expect to have the same problem again in a few short weeks.
Specialty pharmacy should be about more than the medication cost. As ASP’s definition states, it should require special equipment, expertise, or something above and beyond simply dispensing the medication. I have no doubt that for some drugs, the designation is warranted. Here, however, I am skeptical. Compared to a standard retail pharmacy, what the plan’s specialty pharmacy could do differently is not immediately apparent. There is nothing special about Invega, it is just an expensive, injectable medication. On the other hand, what we are providing is special. We are providing care.
