What is a specialty pharmacy?
A specialty pharmacy provides medications used to treat rare or complex health problems. Because these medications aren't used by many people, a local pharmacy won't keep them in stock. We are a distribution channel for high complexity medications that:
- Cost $10K+
- Are limited distribution
- Need special handling, storage or distribution
- Are injected or infused
- Are administered in a doctor's office, hospital, or at home
- Need ongoing monitoring from a health care professional
- Are part of Risk Evaluation and Mitigation Strategy (REMS) program
Specialty and retail pharmacy differences
Specialty pharmacies deliver services that can help your patients get their medication and stay on their treatment plan. These services go beyond what most retail pharmacies provide. Your neighborhood pharmacy is a great option for short-term bugs like an ear infection or the flu or for broadly used medications such as blood pressure or thyroid treatments. But people living with a complex condition may need extra support.
- Walk-in appointments welcome
- Provides over-the-counter medications
- Treats common diseases
- Dispenses medications that typically do not require prior authorization (PA)
- Requires pharmacist review
- Conducts insurance benefit investigation, PA and copay assistance
- Offers ongoing clinical support as needed
- Treats rare or complex diseases
- Provider sends prescriptions directly to pharmacist versus patient
- Delivers medication overnight
Why specialized care matters
When people get a complex diagnosis, it can be overwhelming. And managing chronic conditions can be complicated. So, before we make any decisions, we explore how to care for people in the way they want and need.
We understand the people we care for — the medications they take, services they need and relationships that nurture them. We think about more than people's specialty prescriptions and conditions. We look at their whole health.
Whether they are newly diagnosed or a veteran of their condition, people require different levels of support along their health care journey. We offer the expertise, tools and services they need to get care according to their unique needs.
Optum Specialty Pharmacy supports specialty treatments and takes a hands-on approach to patient care to help support the health and quality of life for each patient.
Here is a quick list of frequently used terms that will help you understand the process.
An appeal is filed when a prior authorization is denied, asking the insurance company to reconsider its decision to deny coverage of a medication, treatment or service.
Because there are many variables associated with each patient's benefits and there may be differences by state and/or by site of care, a benefits investigation helps providers determine benefit design, coverage requirements and coding guidance.
Copay cards are savings programs offered by drug manufacturers to help patients afford expensive prescription drugs by reducing their out-of-pocket costs.
The Free Drug program is an option for uninsured or under-insured patients to help them get medication. Patients can apply for it, and if approved, they will get free medications for the remainder of the calendar year. Each manufacturer has their own approval requirements and may require patients to submit information such as insurance denials or proof of income.
Foundation assistance is monetary aid to help patients afford medication. It is used for government-insured patients or uninsured patients.
These drugs are therapies only made available to a small number of pharmacies who meet manufacturer requirements for distribution.
Prior authorization is a utilization management process used by some U.S. health insurance companies to determine if they will cover a prescribed procedure, service or medication. Most medications need a prior authorization approval before a specialty pharmacy can dispense the medication.
Specialty medications are high-cost, high complexity and/or high-touch pharmaceutical therapies. Specialty medications are often biologics — medications derived from living cells — that are injected or infused.
This term refers to distribution channels designed to handle specialty medications.
Sometimes referred to as one-month free trial that can be dispensed at specialty pharmacies, vouchers are first-fill help patients get from drug manufacturers.
Sharing information through a provider portal streamlines your workflow and saves precious time. The Optum® Specialty Provider Portal is a secure, web-based pharmacy portal.
It gives you access to detailed patient information that can help alleviate some of the tasks associated with prescribing specialty medications.
Sign in to the provider portal to:
- View prior authorization status, initiate appeals and see denial history
- Track prescription status and referral activities with enhanced dashboard views
- Easily search for patient medication lists, allergy information, diagnosis codes and insurance information
- Upload documents
- Chat with us
Talk to your account manager and register to access the provider portal.
- Optum internal analysis. Third quarter, 2021.
- Optum survey. 2018.