September 2020

GLAUCOMA

Pharmaceutical Focus
Utilizing specialty pharmacies


by Ellen Stodola Editorial Co-Director

When confronted with the problems of access to new brand name medications and the potential for generic drug shortages, many ophthalmologists have started using specialty pharmacies.
“Specialty pharmacies are a relatively new tool for ophthalmologists,” said Nathan Radcliffe, MD. “I first learned of specialty pharmacies from a colleague in dermatology who was surprised ophthalmologists don’t use specialty pharmacies to the degree that dermatologists do.”
These are smaller pharmacies that are focused on providing services to patients and doctors rather than treating them as a number, he said.
Dr. Radcliffe said the specialty pharmacy he has worked with is committed to getting patients the medicine prescribed by the doctor, one way or another. “They take it upon themselves to find coupons or get the prior authorization from the insurance company,” he said. “It’s been a good system, and I’ve been able to write brand name medications that I wasn’t able to before.”

Why physicians use specialty pharmacies

Robert Noecker, MD, began using specialty pharmacies several years ago when he was having a problem getting access to new branded medications for patients through traditional pharmacy channels. “It was hard to get things at a reasonable price for the patient,” he said. “We started using specialty pharmacies, and they’re comfortable with eyecare, understand the issues, and can get the best price.”
Michael S. Cooper, OD, also uses specialty pharmacies on a regular basis. “There are several reasons for transitioning into this realm, with the chief reason being they typically have a more hands-on approach,” he said. “Similar to a technician or scribe remembering my habits, so does the specialty pharmacy, [which] in some cases [is] on a first name basis along with recalling my prescribing tendencies for a particular disease state.” Dr. Cooper said these specialty pharmacies seem to have better pricing for certain products with the added benefit of adjudicating the coupons on premises, which cuts down his practice administrative time.
Dr. Cooper also pointed to the connection to the community that specialty pharmacies have. “They are small business owners who live and breathe the day-to-day challenges we all face, especially during this pandemic,” he said. “I know of several specialty pharmacies who went the extra mile before others caught on and began to deliver medications curbside and to the patient’s doorstep.”
According to Jason Bacharach, MD, specialty pharmacies come in “a lot of different flavors.” He noted that many have contracts with branded pharmaceutical manufacturers. This is efficient and cost effective for the patient to get a high quality, branded product, he said. Sometimes, he added, there may be extra legwork required in the office for technicians to recall what specialty pharmacies to send what prescription to, but there is a trend that specialty pharmacies will work with multiple manufacturers, which eases the process.
Dr. Bacharach said these pharmacies don’t have to be in a certain locale since most specialty pharmacies will mail prescriptions to the patient.

Prescribing brand name medications

Dr. Noecker noted that when he is prescribing medication through a specialty pharmacy, he will give the pharmacy a hierarchy of his choices of medication, so there are still options, but the pharmacy knows his top preference.
Dr. Cooper thinks that using specialty pharmacies has allowed him to prescribe brand name medications with greater freedom. “They can source brand medications I would like stocked and keep them in reserve for my patients who are in need of urgent and maintenance therapy,” he said. “Additionally, they are less likely to start getting into a pricing conversation because they know I chose a particular medication for a reason.”
The primary reason to use specialty pharmacies is cost, Dr. Bacharach said. Though it might be easier in some cases for a patient to pick up a prescription at a pharmacy where they have a relationship, the cost is often prohibitive. Specialty pharmacies usually cap the cost and allow patients to get the specific medication they need, he said.

Shortages of generic drugs

Dr. Cooper said that while generic drug shortages are an issue, he relies on multiple pharmacy streams, including specialty, retail, and mail-order. “While the latter two options lean on specific supply chains, which may have been cut off, specialty pharmacies can be nimbler and tap into their network that may include similar or unique sources to leverage their businesses,” he said.
Dr. Noecker has noticed shortages in generic drugs, noting that it seems like each week it’s something different. “It’s devastating when you have 30- to 40-year-old drugs that once were very cheap, and now you can’t find them,” he said. “Drug shortages are becoming the norm.”
Dr. Bacharach said he sees these shortages “all the time.” “You read about it, then all of a sudden, you’re in it,” he said. It can be quite challenging when this happens because patients will call the practice looking for substitutions. It’s an unfair situation for the patients, he said, because often the substitution is the branded product that’s not on a good price tier.
Dr. Radcliffe pointed to the shortage of dorzolamide, which he said began around fall 2017. Multiple generic manufacturers started running out of this, he said, though the reason was never figured out. It could be that some ingredient for it wasn’t available, but since that time, dorzolamide has not been consistently available.
The biggest problem with a dorzolamide shortage, Dr. Radcliffe said, is that one of the more common glaucoma medications uses a fixed combination of timolol and dorzolamide. When a patient goes to the pharmacy and they can’t get this, he or she will go off the medicine. Dr. Radcliffe said he’s seen people go blind because their pressure was out of control in the period between appointments when they were off the medication. Even now, he said it’s hard to write a prescription for dorzolamide and be confident the patient will get it. A potential solution is compounding pharmacies, not specialty pharmacies, which make their own dorzolamide. But he said this option usually does not go through insurance, so there is a different element of difficulty when prescribing.

Benefits to patients during the pandemic

Dr. Bacharach said that anything that can be done to allow for longer refills is helpful. This can cut down on doctor/technician time, “additional touches” in the practice, and facilitate the acquisition of the product for the patient so they don’t have to physically go to the pharmacy. “I think in many cases, specialty pharmacies provide that advantage,” Dr. Bacharach said.
“The pharmacy world as we knew it has changed swiftly for all the players in the nascent COVID-19 world,” Dr. Cooper said. “For those that survive, it will be a matter of developing close relationships with private physician practices, urgent care, and small to large hospital units to minimize the impact on shortages along with overall supply/demand curves.”

About the doctors

Jason Bacharach, MD

North Bay Eye Associates
Petaluma, California

Michael S. Cooper, OD
Solinsky EyeCare
West Hartford, Connecticut

Robert Noecker, MD
Ophthalmic Consultants
of Connecticut
Fairfield, Connecticut

Nathan Radcliffe, MD
New York Eye Surgery Center
New York, New York

Relevant disclosures
Bacharach
: None
Cooper: None
Noecker: None
Radcliffe: None

Contact
Bacharach: jbacharach@northbayeye.com
Cooper: coopadre@gmail.com
Noecker: noeckerrj@gmail.com
Radcliffe: drradcliffe@gmail.com

Utilizing specialty pharmacies Utilizing specialty pharmacies
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