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Specialty pharmacies work with medications that are especially complex, require special handling, or cannot be kept in stock by traditional retail pharmacies. For example, specialty medications include many injectable, biologic products or cutting edge medications. The specialty pharmacy you can use is assigned by your insurance company. The specialty pharmacy gets the prescription from your doctor’s office, takes care of any authorizations that may be needed, fills the medication, and ships it to your house or the doctor’s office for use.
Typically Require Prior Authorization from Plan to Fill
This means that your doctor must provide some more clinical information to the insurance company before they approve your prescription to be filled. The information requested depends on the medication you are trying to obtain and could include blood work, test results, along with a list of other medications that have been tried for your condition. How long this process takes is often dependent on how quickly your doctor’s office can provide it. Once they have the information, the insurance company will make the decision to either approve or deny your prescription.
What if Your Plan Denies the Medication?
You have the right to appeal the insurance company’s decision to deny your medication, as well as explain why a particular medication is medically necessary for your condition. You or your doctor can process the appeal documents by the plan’s deadline dates.
My Medication is Approved, Now What?
Once the medication is approved, the specialty pharmacy will be provided with your insurance information. If you are able to afford your co-pay, the medication will be filled and shipped free of charge, directly to your home or your doctor’s office depending on how the medication is administered.
If the medication’s covered price is too expensive, most drug manufacturers have a co-pay assistance program or can provide co-pay assistance cards to eligible patients which can lower the cost of the medication. Before you pay for the medication check to see if there is a program to help pay for your medication.
Options for the Uninsured
If you do not have any pharmacy benefits there are programs from drug manufacturers that may provide access to the medication—often free of charge! Visit the website for the medication and it will show you a list of options and edibility requirements, along with application instructions.
Other Financial Help Paying for Medications
There are other programs that you may qualify for that can help you pay for your medication co-payments and deductible costs. Depending on your age, income, state you live in, type of insurance or other factors, there could be state, federal or local programs to help you get the medications you need. Inquire about coupon savings cards, charity grants, elderly savings programs or other means of reducing your costs that you could apply for, including programs that will pay for other budget or healthcare items to free up money for medications. In addition to searching online, your pharmacist, as well as your provider, might be good resources to steer you in the direction of a program.
Sometimes Patients Are Not Eligible for Co-pay Assistance
Patients with government-funded healthcare such as Medicare, Medicaid or TRICARE are not eligible for manufacturer co-pay assistance cards. Eligibility varies by program and is usually based on income, you need to apply in order to receive assistance.