In addition to your primary care physician and team of specialists, your local pharmacist and insurance case manager are important members of your healthcare team. Being proactive in establishing these relationships and planning ahead are key steps in preventing medication access issues.
Read below to learn about the different types of pharmacies and other resources available to you.
Retail vs specialty
There are two main types of pharmacies that most individuals utilize, retail and specialty. The main differences between the two is the type of medication they can dispense, and the services offered. Retail Pharmacies (such as your local Walgreens, CVS, or Wal-Mart) are retail. Common medication such as antibiotics, blood pressure, and allergy medications are usually sent to a retail pharmacy and, if you’re lucky, you can pick them up after you’ve done some grocery shopping.
Certain treatments for rare diseases require specialized pharmacists who are knowledgeable about medications for complex diseases. This includes capabilities for researching financial assistance options, side effects, and constant communication with the prescribing provider’s office. A specialty pharmacy can either be a local specialty pharmacy or a mail order pharmacy that is selected by your insurance provider.
While there are many moving pieces, you can work proactively to make obtaining prescriptions as seamless as possible. Ensure all stakeholders have up-to-date, accurate information – your insurance card, phone number, and mailing address are critical to confirm at each encounter. At each visit with your healthcare team, be sure to confirm they have the correct pharmacy on file so that your prescriptions end up at the right place. This is especially important if you have multiple prescriptions sent to different pharmacies (e.g., a retail pharmacy handling a standard prescription and a specialty pharmacy handling another).
Connecting with your pharmacist
Your specialty pharmacist is an important member of your extended healthcare team. When you are first connected with a specialty pharmacy, ask for a direct number. Introduce yourself to the pharmacist and get their name – you may be able to be redirected to the same person in the future should you need to troubleshoot any problems.
The pharmacist can also help you understand important aspects of your prescription. For example, they can identify the tier for the medication and advise of any continual or renewing requirements (such as a prior authorization). Furthermore, if medications require bloodwork or additional paperwork, the pharmacist can guide you to what and how frequently it is needed per your plans policy.
A specialty pharmacy will try to communicate with your prescribing provider’s office via fax to obtain records such as bloodwork or prior authorizations. Unfortunately, often faxes from specialty pharmacies may be sent to a centralized fax hub within your healthcare institution and can be lost in the void of paperwork. Remember, you are an important conduit between the specialty pharmacy and your prescribing provider – connect them to each other by providing the specialty pharmacy your provider’s office line, direct fax line, and be sure to request copies of important correspondence in case they get lost in the shuffle. You should proactively call the providers office if the pharmacy is needing anything from them to prevent delay in receiving the medication. The providers office can also expedite the process from their end too.
Be proactive on annual insurance renewals. Losing your insurance benefits can be very detrimental to yourself or your loved one. Those with Medicaid must complete forms yearly to stay active or your insurance will “lapse” or be “termed.” These are both terms to indicate you no longer have an active insurance plan. Ask your insurance company if you can be assigned to a case manager (or benefits manager) – this is someone who works for the insurance company who helps to oversee and coordinate your case, so that things don’t get lost. A good case manager acts as an advocate for you because, over the years, they will learn what medications you have tried that have worked or that haven’t. A case manager who has a good relationship with you can advocate for you when things come up like denials of payment for medications or procedures. Also, a case manager can help you to understand your co-pay and deductible requirements toward your insurance – which is vital information! Some of the medications for complex disorders are quite expensive and understanding your deductible requirements can make a huge impact on your health and your wallet.
Lastly, ask if your clinic has access to a social worker or case manager you can work with to help you to sort out issues with insurance rejections, applying for disability if necessary, or for looking into other resources in the community. Be proactive annually when looking at your benefits and coverage! Make sure you reach out to the representative for your insurance plan during open enrollment to discuss any questions upfront and how to navigate if coverage of a specific medication or test will be changed. Furthermore, understanding co-pays and deductible plans is essential. Remember, co–pays are forever so do not be shy if a higher deductible is cheaper over the year. There are benefits to both. For those with commercial plans, your human resources benefits department should be able to answer most questions you have, too.
Reviewed by Ashley Pounders, MSN, FNP-C, Director of Medical Affairs, TSC Alliance, November 2023.
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