Dear Addy: Specialty Pharmacy vs. PBM

Dear Addy,

What is the difference between a Specialty Pharmacy and a Pharmacy Benefits Manager (PBM), and why should I care?
Signed,
John, young adult with mild hemophilia A
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Dear John,
The Academy of Managed Care Pharmacy (AMCP) defines a specialty pharmacy as “…distinct from traditional pharmacies in coordinating many aspects of patient care and disease management. They are designed to efficiently deliver medications with specialized handling, storage, and distribution requirements with standardized processes that permit economies of scale.” Specialty Pharmacies are most often focused on dispensing specialty drugs, like factor products that are high in cost, require special handling and shipping, and require special administration to a patient.
A pharmacy benefits manager (PBM) primary job is as a third party administrator of prescription drug programs, managed care organizations, self-insured companies, and government insurance programs.
In addition, PBMs manage pharmacy networks, conduct drug utilization review, and engage in disease management. Like specialty pharmacies, PBMs fill prescriptions often via mail and offer specialty pharmacy services.
In short, PBMs are generally larger organizations than specialty pharmacies with more complex organizational structures that focus on more than just providing specialty drugs.
Why should you care? Because lately many insurance companies are moving patients from specialty pharmacies to PBMs that are unfamiliar with the needs of bleeding disorders patients. If this happens to you, and you do not want a pallet of factor delivered to your house along with non-sterile syringes (true story), then you will need to either request that you keep the specialty pharmacy who knows and meets your needs or educate the new pharmacy about your needs.
If you have already faced trouble from such a switch, we want to hear about it! Your voice can help us effect positive changes in service for the bleeding disorders community!
Sincerely,
Addy
Have a question? Click HERE. Your name will be changed in the response.
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HFA frequently receives questions from the bleeding disorders community related to advocacy issues. The questions often impact the entire community. In an effort to reach the largest audience possible with our responses to these widely applicable questions, HFA developed “Dear Addy.” Questions submitted to this column are edited in order to protect privacy and should be considered educational only, not individual guidance.