Where High-Performing Specialty Pharmacies Focus Today

As specialty medications continue to dominate new therapy approvals and overall drug spend, the performance of the specialty pharmacy becomes increasingly consequential.

Specialty pharmacy success is not static; it requires continuous monitoring and deliberate refinement across multiple operational levers. Many variables factor into the successful operation of specialty pharmacies, including focused efforts in the following areas:

Streamlining prior authorizations. Health systems are tearing down administrative hurdles for prior authorizations by embedding specialty pharmacists in clinics and investing in centralized hub strategies to handle authorizations systemwide. This includes integrating artificial intelligence (AI) tools in real time to align with payer rules and file appeals swiftly.

Gaining payer access through accreditation. Obtaining credentials from the Accreditation Commission for Health Care (ACHC) and/or URAC, formerly known as the Utilization Review Accreditation Commission, remains a fundamental way to help health systems gain payer access. It’s an important step that empowers health systems to leverage their high-touch clinical model as a selling point to payers.

Increasing prescription capture rates. Specialty prescription capture rates have been a persistent challenge, and those lost prescriptions represent forgone margin and fragmented care. Health systems are ramping up efforts to keep prescriptions in-house and using data to pinpoint where patients are being diverted. Prescribers are also being educated to effectively advise patients about the benefits of using the internal pharmacy, including continuity of care, faster time to treatment and expanded financial support. In the future, look for more technology solutions that seamlessly route e-prescriptions to the health system pharmacy along with greater payer engagement by health systems and their vendor partners to advocate for in-network inclusion.

Breaking down limited distribution drug (LDD) barriers. Health systems remain frustrated by LDD barriers, citing delays in therapy starts and fragmented care when patients must coordinate with an external specialty pharmacy that doesn’t share their electronic health record (EHR). Typically, health systems must navigate each LDD on a case-by-case basis. Because these negotiations are time-consuming, health systems are turning to specialty pharmacy services administrative organizations (PSAOs) that contract with payers on the system’s behalf to satisfy access requirements.

Optimizing 340B strategies. Due to the complexities and dynamic nature of the 340B program, specialty pharmacy services optimization is a moving target for health systems with robust 340B programs. However, 340B’s deep impact on specialty pharmacy profitability makes it worth the effort. Success will likely require a combination of internal experts, external vendors and advanced platforms to monitor and comply with ever-changing program requirement.

Our Second Health System Pharmacy Market Outlook Report offers more guidance for pharmacy professionals as they look to shore up specialty pharmacy operations. Download the report now: