Why Payors Should Evaluate Provider-Based Specialty Pharmacies Seeking Network Access

John Reddan and Brian Romig, Pharmacy Practice News

Health-system specialty pharmacies are emerging across the United States to improve access to specialty medications, better serve patients, and, in many cases, capitalize on their 340B status and access to statutory drug pricing.

According to analyses, 20% of systems already have internal specialty pharmacy capabilities, with 40% considering adding these capabilities. Furthermore, from 2015 to 2016, specialty pharmacy ownership by healthcare providers grew 122%. 

However, these pharmacies often are excluded from health plan and pharmacy benefits manager (PBM) networks, and are therefore unable to service commercially insured patients. Such exclusion runs the risk of increasing costs and compromising patient care.

Health plans, and PBMs on their behalf, have restricted distribution networks to the specialty pharmacies they own and operate as a means of controlling costs and maximizing financial performance. Because of this, health-system specialty pharmacies often are limited to “grace fills” — when a prescription is allowed one fill before it is transferred to an in-network pharmacy — and serving government business through “any willing provider” statutes. In many cases, health-system specialty pharmacies can’t even service their self-insured population, an unfortunate situation because they’re well positioned to outperform “external” specialty pharmacies, both clinically and financially.

Across all clinics, VUMC has documented an overall monthly medication possession ratio of more than 96% (80% is considered the “gold standard” for chronic inflammatory disease).

Read Why Payors Should Evaluate Provider-Based Specialty Pharmacies

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