The source from which a patient receives their specialty medication dosage should be straightforward and consistent; either the drug is delivered to their homes, or they go see their doctor for an injection or infusion. The managed care system, which is the system of healthcare insurance plans (ie. HMO, PPO, or POS) and drug delivery options (ie. specialty pharmacy delivery or medication dosing in the prescriber’s office) is designed to keep cost to the patient down while providing the best quality of care.
For a variety of reasons, the payer may decide a drug that was once delivered via specialty pharmacy should now be dispensed in the prescriber’s office, or vice versa. Factors behind this decision can include: “unprecedented high launch prices, complex third-party logistic expertise, intricate supply chain requirements, exclusive distribution rights, and [specialized training requirements] for administration and monitoring”. This change most often happens to drugs that recently received FDA approval, or for newer biotech drugs such as gene and cell therapies. In other words, the technology and level of sophistication of certain drugs is evolving faster than the managed care system, so it is not always immediately clear where a given drug fits best in the managed care system.
While changes to the managed care system are happening behind the scenes, patients who are taking the drug could end up dealing with repercussions that may result in treatment delays if the switch is not being properly tracked. For example, patient savings programs are easily accessible through a dispensing pharmacy, but a sudden switch to medication dispensing at the physician’s office can mean a change in how the payer covers the drug. Without proper tracking of that patient’s eligibility of the patient savings program and their claim history, the patient may need to wait until the prescriber submits the paperwork and the payer makes a determination.
Brands can help mitigate gaps in treatment for their patients by working with a service provider that is skilled in handling managed care coverage changes. The ConnectiveRx data platform has the ability to track the patient regardless of such changes. This means that whenever there is a shift in coverage, the patient doesn’t have to re-enroll into their copay program, which could lead to treatment delays. Furthermore, having the data available to see shifts in managed care allows brands to understand the true value of their copay program because there is no lapse in coverage and usage.
Changes to the ways in which specialty medication is dispensed are common, yet they still threaten to disrupt the patient journey. Working with a partner like ConnectiveRx is a proven way to help patients stay on their medication despite the obstacles. Learn more about how we work with brands to navigate changes to managed care scenarios by reaching us at Inquiries@ConnectiveRx.com.