The Good, Bad, and Ugly of Specialty Pharmacies
Last updated: August 2023
For the last 6 months, I’ve been navigating the special pharmacy world extensively. For a variety of reasons, my health insurance benefits changed 3 times in that span of time. And just like everything else connected to health insurance, it’s not been an easy journey.
This article is to guide you, dear reader, through my mistakes and how I overcame challenges for me as I dealt with specialty pharmacies filling Keegan’s prescription for Humira, which he’s been on now for about 6 years. One big caveat before diving into the details: Keegan and I have private health insurance through my employer in the United States. I’m not sure what this process is like with other insurance, like Medicare or Medicaid.
What makes it so difficult?
Getting prior authorization is confusing and can take a while
Before we even could fill a prescription, Keegan’s rheumatologist had to get a prior authorization. Essentially, it’s a form that the doctor filled out to get approval from the insurance company that they would cover Humira. Initially a few years back, Keegan’s doctor wanted him to go on Remicade first, but the insurance wouldn’t allow it. So it took a few weeks of back and forth between the doctor, us, and the insurance company.
Then, we had to figure out which specialty pharmacy to use
Across 6 years, we always had to figure out which specialty pharmacy aligned with our health insurance plan. That is, it’s unlike typical prescriptions where we can go to CVS, Walgreens, etc. It’s sometimes a 1-to-1 relationship where the plan you have only allows 1 specific specialty pharmacy.
Rarely can you find these prescriptions in a brick and mortar store
When Keegan needs a refill, it always has to be done through the specialty pharmacy. The neighborhood CVS never carries Humira or similar medications.
Humira, and similar medications, need to be shipped and stored in a cool place
Yes, we needed to time the delivery just right to make sure Humira got into our fridge quickly. It typically comes in a box with ice packs to keep it cold just for a little bit until we’re able to get the package and get it into the fridge.
Refills don’t happen automatically
None of the specialty pharmacies we’ve used before allow for auto refill. (I assume this is due to how expensive Humira is to fill.) So, Keegan always has to request a refill via phone or online. (One specialty pharmacy always required a phone call.)
What tips and tricks do you have for someone who uses specialty pharmacies?
Ask your rheumatologist for refills when in an emergency
When Keegan’s been in a pinch for medication, many of Keegan’s rheumatologists gave him a dose to cover him until his refill came.
Save all your specialty pharmacy info
Whether it’s a notebook or Google, save the phone number, specific prescription information (like dosage and frequency), and pharmacy benefit information so every time we refill, we have all the information at our finger tips.
Put your refills on a calendar
We use a digital calendar with a recurring reminder to order more refills to avoid gaps in medication.
Hopefully this gives readers some insight into the process of filling Humira and other biologics at a specialty pharmacy. For others who’ve gone through this experience: what are your tips and tricks?
Has changing your diet helped manage your pain and flares?