The number of specialty pharmacies to be included in the network is highly dependent on the size of the patient population expected to be treated with the therapy being commercialized. The larger the patient population, the more pharmacies are likely to be included in the network.
Depending on the disease status, product considerations and the expected size of the patient population, certain specialty pharmacies are considered. For example, if a biopharmaceutical manufacturer markets an oncology product, they should consider oncology-focused specialty pharmacies.
Likewise, if a product is extremely rare, a specialty pharmacy focused on rare diseases is the obvious choice.
Payer and reimbursement factors also play a role in the number and type of specialty pharmacies that are included in the network. A biopharma company must ensure that the network they select has broad coverage from the major payers to guarantee product reimbursement. This can be achieved by selecting all pharmacies owned by the Pharma Benefit Manager (PBM).
Alternatively, a manufacturer can select all independent pharmacies without access to the product to the PBM-owned pharmacies, thus preventing payers from requiring the product to be filled in their pharmacies.
Once the strategy for commercial specialty pharmacies is understood, a decision is made on whether or not to include a hub service provider in the network. If the patient population is small and the manufacturer opts for an exclusive model in which a single specialty pharmacy has access to the product, it may not be necessary to include a hub.
However, as the number of pharmacies grows, positioning a hub as the ‘quarterback’ of the network becomes the right choice.
“So why do I need a hub when specialty pharmacies can do it?”
The value of a hub service provider
A hub can play an essential role in coordinating the limited distribution network of the specialist pharmacy. While specialty pharmacies may be able to provide some of the services a hub provider provides, a hub can standardize patient and caregiver support across the network and coordinate referrals to ensure patients reach the most appropriate destination.
Referral Alignment: Depending on whether the hub model is mandatory or not, referrals can end up in multiple places within the network. The right hub strategy uses a proactive approach to align referrals across the network and ensure no patients are left behind. If referrals are at a stalemate or are served by multiple pharmacies at once, causing unnecessary payment blocks, the hub can step in to help. This ensures that only one pharmacy takes the patient to therapy or prevents interruption of therapy.
Advanced Network Triage: Sending hub referrals to the right pharmacy is an important role that only a hub can play. If the right hub strategy is chosen, it can set automated triage rules based on payer mandates, physician preference, round robin, and other rules to ensure referrals reach the pharmacy most likely to getting a paid claim. When done right, a hub can have a huge positive effect on time to therapy by minimizing network transfers.
Improved data visibility: A hub plays an important role in increasing the authorization and consent rates of the Health Insurance Portability and Accountability Act (HIPAA) in supplemental programs. Referrals can come into the hub with patient signatures. If not, the hub can follow up during a welcome call to obtain consent, ideally digitally via e-consent. With increased HIPAA authorization rates, the manufacturer gains more data visibility. In addition, if the right hub strategy is chosen, it can establish data agreements across the network to improve data visibility, allowing it to play an active role in matching referrals.
Customizability: Hub providers have a core set of services they offer, but also have the ability to customize heavily if needed. This includes customizing the process flow based on patient and caregiver needs, patient engagement trajectory, and data reporting. The right hub strategy is agile, capable of making process changes in the blink of an eye, and captures every element of data needed for reporting.
Other important services a hub offers
Case management and field team support: A hub may employ dedicated case managers who serve as the primary point of contact for patients and prescribers. They can help patients navigate their journey to treatment and beyond. They can serve as patient advocates. They can also assist healthcare providers in prescribing the medication and send field-based team members to properly support prescribers.
Reimbursement and support for own payment: Depending on the model, the hub can assist with drug reimbursement and co-pay support. In a mandatory hub model, the hub conducts detailed benefits research, supports prescribers through pre-authorizations and appeals, and assesses clean claims to pharmacies before dispensing. Once launched, a hub can quickly learn payer requirements, stay on top of formulary updates, and work with the manufacturer’s market access team to optimize payer coverage. For commercially insured patients, the hub can enroll them in a co-payment program and pass the co-payment identifier to the pharmacy for use in the arbitration, minimizing out-of-pocket costs for the patient.
Nurse Navigator and Psychosocial Support: A hub can increase patient involvement through nursing and psychosocial support. Nurse navigators can serve as an aid to the patient through education about disease conditions. They can conduct needs assessments to understand the patient’s knowledge and familiarity with their diagnosis. They can assess and guide the patient’s support system during their journey. They have set the expectation for the next steps regarding specialist pharmacy coverage and triage. Based on needs assessment findings, nurse navigators plan follow-ups to discuss appropriate topics that are beneficial to the patient.
Qualification of free medicines and dispensing of non-commercial pharmacies: A hub can manage free drug programs such as patient assistance, bridge, quick start, dose exchange, vouchers and other forms of “free” drug programs. This includes qualifying patients based on company rules and triage to a non-commercial pharmacy for dispensing. Ideally, the hub owns a non-commercial pharmacy licensed in 50 states. Having an in-house non-commercial pharmacy avoids roadblocks associated with an outsourced pharmacy that may not be able to accommodate specific program nuances.
Clinical Support for Patients: If the hub uses nurse navigators for illness and psychosocial support, the non-commercial pharmacy can use clinical support from pharmacists for patients taking free medicines. Clinical pharmacists can inform the patient about the medication, the side effect profile and possible drug interactions. They can determine the expectation of the benefit of taking the medication, what to do if doses are missed, how to store the medication, and answer any questions you may have. If the medication requires titration, weight dependent dosing or special dosing considerations, the pharmacy can support patients and prescribers through proper administration and dose optimization.
Education for healthcare providers: This includes educating prescribers on how to send full submissions, guiding them through the reimbursement process, and assisting them with drug prescribing and dose adjustments. The hub can provide prescribers with a dedicated point of contact for protocol support.
Implementation of the REMS program: If the FDA requires a REMS program, the hub can adjust the process flow to meet REMS requirements. This may include the requirements of the Medication Guide, guiding prescribers to enroll in a program and provide appropriate attention, enrolling patients and advising them on potential risks, verifying these enrollments prior to submission, reporting adverse events, etc. .
Data reporting, analytics and digital solutions: In addition to the services discussed above, hubs communicate activities to the manufacturer through reporting and analytics. Standard reports contain status, issue, and inventory files. Hubs have experience working with data aggregators, have the ability to deliver custom reports, and have the ability to provide real-time insights. Other digital solutions include SMS and e-mail capabilities, e-consent, electronic prescribing, etc.
Selecting the “correct hub”
As with selecting specialty pharmacies, it is preferable that the hub is focused on the treatment area, such as rare diseases for an orphan drug or oncology focused for a cancer drug. In addition, the right hub is dedicated, proactive, has an eye for detail and plays an active end-to-end role in the network.
The right hub is agile, quickly adaptable and delivers on its promises. Likewise, the right hub has its own non-commercial pharmacy that provides a consistent experience with the commercial specialty pharmacies in the network and integrates seamlessly with the patient service provider.
Basically, the right hub service provider acts as an internal, external hub for the manufacturer, running their brand support program flawlessly and setting up the limited distribution network to succeed.
About the author
Rami Chammas, PharmD, MPBA, is the Director of Pharmacy Services at RareMed Solutions, the nation’s first rare disease specialty pharmacy center. Chammas oversees pharmacy operations and non-commercial program services for pharmacies. Before taking on this role, Chammas led the implementation efforts at RareMed by successfully implementing numerous patient support programs across multiple disease states. Chammas began his journey through specialty pharmacy at PANTHERx Rare Pharmacy, where he was involved in projects across many departments, including quality, product development and strategic partnerships.
Chammas received his doctorate in pharmacy from the University of Pittsburgh School of Pharmacy and is currently pursuing a Master of Pharmacy Business Administration from the University of Pittsburgh, a 12-month, executive-style graduate education program designed for working professionals who aspire to shape the future of to be tomorrow. leaders in medicine.