What is a Medicare Specialty Pharmacy?

Medicare Specialty Pharmacies

Medicare Specialty Pharmacies - Why They Matter

If you have Medicare for your health care coverage, then it is also possible that you have a Medicare Part D prescription drug plan – either as a stand-alone policy or as part of a Medicare Advantage plan – to help you with the cost of your medications.

Depending on your health condition, as well as the medication(s) that you’ve been prescribed, it could also be that some or all of the drugs that you require must be obtained through a specialty pharmacy. (*Related Post – Why Tiers Matter: Checking What Your Prescription Medications Will Cost You)

Specialty Pharmacies and Specialty Pharmaceuticals

A specialty pharmacy is defined as a service that has been created for the handling, management, and servicing of specialty pharmaceuticals. This includes the dispensing and the distribution of such drugs, as well as case management, reimbursement, and / or other services that are specific to those who have rare or chronic health issues that require such specialty pharmaceuticals.

Specialty pharmaceuticals, then, are generally defined as products that are used for the treatment of chronic, rare, and / or high cost health conditions. This type of medication can be taken orally or injected, as well as inhaled or infused.

Because specialty pharmaceuticals are oftentimes more complex to administer and to maintain, as well as more complicated to monitor – as versus more “traditional” medications – these specialty drugs will typically require closer supervision in a patient’s overall therapy.

Some of the primary characteristics of specialty pharmaceuticals can include some or all of the following attributes:

  • Regular / frequent adjustment of the dosage
  • Administration of the dosage with injectable and / or infusible drugs
  • Requirement of special handling, storage, and / or administration to the patient
  • A narrow therapeutic range
  • Periodic lab or diagnostic testing
  • Higher costs than traditional medications (sometimes as high as $100,000 per year, or more)
  • A small number of individuals who use the medication
  • Patient registration requirement before being approved to take the medication
  • Patient training and / or a clinical call center that can offer patient assistance
  • Compliance management
  • Clinical analysis and data reporting

In addition, it is possible that specialty pharmaceuticals may also have more severe side effects than traditional medications cause.

Typically, specialty pharmaceuticals can be defined, and in turn, classified by how they are administered – and oftentimes, these medications can be broken down into four distinct categories, including:

  • Select oral agents
  • Self-administered injectable medications
  • Office-administered injectable medications
  • Clinic or office administered infusible medications

The Key Focus Areas of a Specialty Pharmacy

When there were initially introduced into the industry, specialty pharmacies began with “pockets” of independent pharmacies that attempted to fill certain gaps in the traditional pharmacy practice. For example, some of these gaps included certain treatment regimens, the management of more complex health issues, and / or certain types of challenging reimbursement situations.

Today, specialty pharmacies are generally centered on the dispensing of medications that are used to treat specific health conditions, such as:

  • Cancer
  • Multiple Sclerosis (MS)
  • Pulmonary Hypertension
  • Hemophilia
  • HIV / AIDS
  • Rheumatoid Arthritis
  • Hepatitis C
  • Crohn’s Disease

With that in mind, specialty pharmacies will generally provide the following benefits:

  1. A way to manage the cost of specialty pharmaceuticals for the patient, and
  2. The opportunity to save money for the benefit sponsor (as compared to the more “traditional” models of medication delivery where products may not be sent through more efficient means).

Medicare’s Coverage of Specialty Pharmacy Products

If you have a serious and / or chronic health condition that calls for specialty medication, then you may find that you are required to pay a great deal of money out-of-pocket in order to obtain those drugs – even if you are covered under a Medicare plan.

For instance, in 2016, such out-of-pocket costs reached as high as $11,538 for a single “covered” medication – which is much more than the 2016 annual maximum catastrophic threshold of $4,850 (which is otherwise termed as the upper limit of the Medicare Part D donut hole).

And if your medication has been excluded altogether from your Medicare Part D drug plan, then the costs can be even more astronomical – in some cases exceeding $50,000 per year, or higher.

How can this be?

Each Medicare prescription drug plan has its own specific list of covered drugs. This list is typically referred to as a formulary. The medications are further broken down within the formulary into different “tiers” – and the medications within each of the tiers can have different costs. (Note that because there are many different Medicare Plan D prescription drug plan options, not all formularies or tiers are the same).

A medication that is listed within a lower tier will typically cost less than a medication that is in a higher tier. So, before you choose a Medicare prescription drug plan, it is important to make sure that your drug(s) is / are covered by the plan.

If, however, you take a prescription medicine that has been excluded from your Medicare Part D drug plan, then the out-of-pocket cost responsibility can be quite high for you. Also, because Medicare prescription drug plans are not offered by Medicare itself, but rather through private insurance carriers, the actual coverage may differ – sometimes substantially – from one of these prescription medication plans to another.

In addition, there are Medicare prescription drug plans that will require that you and / or your doctor obtain prior authorization from the plan before the plan will cover the medication. For instance, it may be required that your medical provider prove that the medication is in fact medically necessary to treat a condition that you have.
There may also be quantity limits placed on how much of a certain medication you can obtain at any one time. This can also help the Medicare drug plan to reduce the likelihood that certain medications will be abused and / or inappropriately distributed.

Protecting Yourself from High Out-of-Pocket Prescription Medication Costs

So, how can you help to protect yourself from such astronomical out-of-pocket expenses?

One of the best ways is to really shop around and compare Medicare drug plans before you commit to purchasing one. As an example, in 2016, it was found that Spiriva – a medication that that is commonly used with those who have COPD (chronic obstructive pulmonary disease) – cost an enrollee just $33 under one plan, but more than $470 with another – nearly 15 times more.

Given that, not only is it important to make sure that your prescription medications are covered by a plan, but it is also essential to know just how much your portion of the cost responsibility will be. Knowing this up front can help to alleviate an unpleasant surprise down the road.

In addition, there may also be some help with Medicare’s prescription drug-related costs coming from proposed new legislation. Recently, the Centers for Medicare and Medicaid Services (CMS) proposed a rule that has the intention of ensuring that Medicare enrollees have access to a wider variety of more affordable medications, while at the same time vying to help with combating the opioid epidemic.

This rule would also provide Medicare beneficiaries with the ability to fill their prescriptions at a wider range of pharmacies by eliminating many of the hurdles that can oftentimes stand in the way of obtaining lower cost alternatives for patients.

How to Find Out More If You Require a Specialty Pharmacy for Your Medication(s)

If you are in the process of searching for the best Medicare prescription drug plan – or if you want more details on exactly what your current prescription drug plan covers – you can contact your plan carrier directly. Likewise, discussing your coverage with a third party independent insurance agent who specializes in Medicare plans can also be beneficial.

In order to locate and obtain information on Medicare prescription drug plans, you can also go directly to the Medicare website by clicking here to complete either a general or a personalized drug plan search.

In order to do so, you will be asked to provide your zip code for completing general search, and your zip code, your Medicare ID number, your last name, and your date of birth if you want to complete a more personalized Medicare Part D plan search. For any additional questions, you can also contact Medicare directly, toll-free, by calling 1-800-MEDICARE (1-800-633-4227).


1. Specialty Pharmacy in Community Pharmacy: The Time Is Now – and How! National Association of Chain Drug Stores.
2. Specialty Drugs Can Prove Expensive Even with Medicare Coverage. Shots – Health News From NPR. December 3, 2015. 

3. How Will Proposed Medicare Part D Changes Affect Specialty Pharmacies? Specialty Pharmacy Times. 

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Author Bio: Ben started Prepare for Medicare in 2014 to help people help people get objective answers to questions about Medicare. He’s held leadership roles at numerous Fortune 500 Medicare health insurers in product development, sales, marketing and strategy for over 20 years.