Ok. You just saw your dermatologist and the plan is for you to start a biologic medication for your psoriasis. Yay! You’re on the way to clear skin and can just stop by your local pharmacy to pick it up today, right? Wrong! Biologics are a part of a group of drugs known as specialty medications and there are several steps needed to get them approved.
Just so you know–there is no universal definition of a specialty medication but there are some common characteristics. Specialty medications are used to treat chronic and rare diseases like cancer, multiple sclerosis and psoriasis, and they account for most of the drug spending in the US. Most specialty medications are created through a complex biotechnology process and carry a hefty price tag as a result—translation—they are expensive and require a prior authorization (PA) for insurance approval. Specialty medications might have specific storage needs like refrigeration and are typically more complicated to administer and are often given by injection. For specialty drugs, it’s essential to have clinical support—meaning patients are educated on their condition and the specialty pharmacy process. I talk patients through the need for regular follow up and following the dosing schedule and consistent communication with our office and their specialty pharmacy. In the skin world, specialty medications include what we call the biologics, hedgehog inhibitors, JAK inhibitors, TYK2 inhibitors, and yes, even botulinum toxin, (aka Botox). If you’ve ever been prescribed one of these medications, you know it’s quite a process to get them from the pharmacy and into your hands.
To get a specialty medication, your insurance will use what is called a specialty pharmacy. A specialty pharmacy exists for the purpose of, you guessed it, dispensing specialty medications. Specialty pharmacies may be owned privately or by different groups like health plans, pharmacy benefit managers (aka PBMs and more to come on this later), retail/community pharmacies or wholesalers. Often your insurance decides which specialty pharmacy you can use. Specialty pharmacies are different from your local pharmacy and often provide more support and guidance with getting insurance approval and may ask you about how well your medication is working for your condition.
Before you are approved for a specialty medication, your dermatologist will start a prior authorization (PA), a process with your insurance company to approve a medication. This requires paperwork and information about why you need the medication and other important points like: What have you tried before? And, what other medications haven’t worked for you? A PA can be approved or denied, based on the information provided and the coverage offered by your insurance. If denied, the decision can be appealed. PAs can sometimes have a long turnaround time and if approved, may need to be done every year, even if you are doing well on your medication.
Trotter’s Take: Specialty medications are indeed special, different from your average prescription and come with a more challenging approval process, but they are worth it if appropriate for the patient.
Take a listen to my podcast with Janelle Ball, host of That’s Derm Good podcast, as we talk through the complex world of specialty medications.
