Improving the Patient Experience in Receiving Specialty Medications

Simplify the process by which patients receive biologic medications.

Challenge Overview

Challenge Description

In the United States, some medications have a specialized fulfillment process which can be challenging for patients to navigate. Specifically, biologic medicines are dispensed by specialty pharmacies that deliver by mail-order only, ensuring the medication is appropriately stored and refrigerated throughout the delivery process. 

As a patient, working with a remote specialty pharmacy can be less transparent than a neighborhood-based retail pharmacy. Examples of this include patients not knowing: which specialty pharmacy their insurance authorizes to deliver their medication, when it will be delivered, or how to easily reach the specialty pharmacy for updates or to make changes to the scheduled deliveries.

The goal of this challenge is to simplify the filling of biologic prescriptions for patients in order to improve access to medicines. The proposed solution should:

  • Track the journey of a biologic prescription and provide status updates to patients on demand
  • Be patient friendly, i.e., usable format, easy accessibility, respects patient privacy
  • Offer a business rationale for specialty pharmacies to participate and share data

This solution should be implementable across all specialty pharmacies. The “challenge guidelines” and “additional context” pages describe in more detail the specific steps of the prescription journey that should be covered, along with context on biologic medicines and how the prescription system works currently in the US. Ultimately, by creating more transparency about biologic medicines and prescription status, we hope to help more patients receive the medications they need, when they need them. 

This challenge is a call for ideas, and subsequent challenges may build out the technical, regulatory, and economic considerations in more detail for the winning solution. 

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Additional Context

Additional Context

Challenge Resources:

Biologics Context

Biologic treatments are protein-based drugs developed from living cells that are given by injections or intravenous (IV) infusions. They differ from small-molecule drugs (which typically appear as more familiar pills) in ways that affect their cost, production, and administration. The nature of their composition (fragile biological macromolecules and living cells) make biologics complex to transport and store, requiring special handling and refrigeration. As a result, payers exert greater control over handling of biologics, and biologics are usually delivered to patients through specialty pharmacies. 


Specialty Pharmacies Context

Getting prescriptions, particularly for biologics, is currently not an easy process for patients. Due to the special characteristics of biologics mentioned above, patients must receive them from so-called specialty pharmacies who will deliver the prescription by mail. 



The process of being prescribed, and ultimately receiving, a biologic medicine typically looks like the following:

  1. Healthcare provider prescribes a biologic: A healthcare provider determines that a biologic medicine is the appropriate treatment for a patient.
  2. Office staff sends prescription to specialty pharmacy: A staff member in the medical practice will electronically send the prescription to a specialty pharmacy. In some cases, they send it directly to the specialty pharmacy that is mandated by the patients’ insurance. In other cases, they send it to a specialty pharmacy that the practice frequently works with – and if the patient’s insurance objects, then the prescription may need to be re-routed.
  3. Specialty pharmacy checks insurance coverage: The specialty pharmacy first needs to confirm whether a patient’s insurance will cover the prescription. This process is called a “benefits investigation”. The specialty pharmacy contacts the patient’s insurer to understand what the patient pharmacy coverage is. The information collected during the benefits investigation includes, but is not limited to, specific specialty drug coverage depending on past medications for a given diagnosis, patient financial responsibilities (co-pay, co-insurance, etc...) and current level of deductible.
  4. Office staff, specialty pharmacy, and insurance company exchange paperwork: In case of biologic therapies, insurance companies often require offices to obtain a prior authorization (PA). The PA paper work is based on the patient’s insurance requirements. If the insurance company denies the initial PA, the office may appeal against the denial and submit additional documentation. And occasionally, if the insurance company makes a final decision to reject coverage, then the office staff may fill out new paperwork to request free medicine directly from the pharmaceutical manufacturer.
  5. Specialty pharmacy sends the medicine to the patient: Once the prescription has been confirmed, the specialty pharmacy will contact the patient to coordinate delivery by mail. Because the biologic medicine needs to be refrigerated, the specialty pharmacy needs to agree with the patient on delivery time before they can ship the product.

Patient Context:

When patients encounter the specialty pharmacy process for the first time, they may be more familiar with filling prescriptions for an oral or topical medicine from a retail pharmacy. Key differences in that experience include:

  • Mail-order: The specialty pharmacy is mail-order only, which means the patient will need to learn a new process to fill his or her prescriptions, instead of using the familiar routine of visiting the retail pharmacy.
  • Time: It takes much longer to receive than the prescriptions from a retail pharmacy because (a) longer insurance approval process for biologics and (b) logistics of sending and receiving mail order. Patients are often unaware of when to expect their prescription to be delivered, and may not even know at which stage in the process their prescription currently sits.
  • Transparency: The patient receives very limited information about the specialty pharmacy itself. In some cases, the patients may not even know who their specialty pharmacy is until they are contacted to schedule a delivery. In order to get updates about the prescription, the patient may call their specialty pharmacy directly (if known) or contact their doctor’s office and ask them to call the specialty pharmacy.

Some patients who do not understand these differences give up and do not ever receive their medicine. Those that do still have to handle weeks of uncertainty as the specialty pharmacy, healthcare practice, and insurance company correspond. And because this process requires significant support from healthcare practices, some doctors do not prescribe biologics and refer patients who need them to other physicians – adding more strain to the healthcare system. A transparent tool with on-demand status updates would help patients, as well as their providers, receive important medications in a timely and transparent manner. 

Community Guidelines