One of the main treatments for advanced prostate cancer is medication to stop the cancer cells from using male sex hormones as fuel. Some of the drugs your doctor is likely to prescribe don’t come from your neighborhood retail pharmacy, but from a specialty pharmacy. These businesses are able to handle complex medications and can help you with other parts of your cancer care.
If your prostate cancer prescription is being filled by a specialty pharmacy, here’s what you need to know.
What Is a Specialty Pharmacy?
A specialty pharmacy handles expensive, complicated medications. Often drugs used to treat cancer, chronic autoimmune conditions, and rare genetic diseases fall into this category. Some of the reasons a drug would be dispensed from a specialty pharmacy are:
- It needs to be shipped, prepared, and stored in a special way, such as with refrigeration.
- The pharmacist has to be specially trained to handle it.
- You need special instructions on how to take the medication or need to be watched carefully while you’re using it.
Because these drugs are very expensive, it’s important to limit mistakes that would cause them to be wasted.
What Medications Would Be Filled at a Speciality Pharmacy?
Hormone therapy is a main treatment for metastatic castration-sensitive prostate cancer (mCSPC). Several commonly prescribed hormone therapy medications can only be purchased through a speciality pharmacy.
Androgen synthesis inhibitors
Abiraterone acetate (zytiga) is approved in combination with the corticosteroid prednisone to treat mCSPC. It blocks your body from making male sex hormones, called androgens, in places other than your testicles, including your adrenal glands and prostate cancer cells themselves.
Anti-androgens
There are several newer types of anti-androgens that prevent androgens from attaching to cancer cells, starving them of fuel.
These newer FDA-approved anti-androgens include:
- Apalutamide (Erleada)
- Enzalutamide (Xtandi)
- Darolutamide (Nubeqa)
These are usually prescribed in combination with other forms of hormone therapy.
How Do You Find a Specialty Pharmacy?
You probably won’t have to find a specialty pharmacy on your own. Most insurance companies have you use a particular specialty pharmacy — either their own or one they contract with. Sometimes a drugmaker only distributes its medication to certain pharmacies.
Prices can vary, so if you do have a choice, it may pay for you to shop around. Once your doctor decides on your treatment, they’ll send the prescription to the specialty pharmacy, which will contact you to begin the process of getting you your medication.
Services Specialty Pharmacies Offer
Like all pharmacies, specialty pharmacies do more than simply fill your prescription. But the services they offer are somewhat different from what you can expect from retail pharmacies.
Financial help
Specialty medications for advanced prostate cancer can cost you hundreds and even thousands of dollars a month. Specialty pharmacies work to make sure you can afford your prescription. Here are some places they look for savings:
Insurance benefits. Specialty pharmacies know the ins and outs of prescription drug coverage through job-based plans, private plans, and government-funded plans like Medicare. They work with your doctor to get the information the insurance company needs to approve the prescription.
If your insurance company doesn’t cover your medication or charges you a price you can’t afford, the specialty pharmacy can give you advice on appealing the decision.
Drug company assistance. The makers of expensive specialty drugs often have programs to help you with your out-of-pocket costs. These include copay cards for people with commercial health insurance and patient assistance programs for people who don’t have insurance or whose insurance doesn’t cover the medication.
Charitable organizations. Many nonprofit groups also offer financial assistance programs for people who can’t afford their medications. That includes people on federally funded plans like Medicare.
Federal and state programs. You may also qualify for government prescription-drug subsidies like the Extra Help program for people with Medicare and Medicaid.
Specialty pharmacies are very familiar with cost-cutting strategies and can help you find out if you’re eligible and how to apply.
Education and follow-up
The specialty pharmacy works closely with you to make sure you understand how to take your medication and how to store it. They check for possible interactions with other drugs you’re taking and go over any special instructions like foods to avoid.
They have pharmacists on call who you can talk to whenever you need to — day or night. They also follow up with you about your symptoms and any side effects you’re having and make sure you’re following your doctor’s instructions.
Refills
With other prescriptions, you can usually request a refill online. That’s another way specialty pharmacies are different.
Someone checks in with you when it’s getting to be time for a refill. They find out whether your doctor has changed your medication or the dose and confirm whether you took your original prescription as scheduled. They also check with your insurance company about any changes to your benefits or their coverage rules.
Does Insurance Cover Specialty Pharmacy Medicines?
The hormone therapy specialty drugs you’re prescribed for mCSBC are generally covered by both job-based and private insurance policies, as well as Medicare. But there are usually steps you have to follow that a specialty pharmacy can help you with.
Prior authorization
It’s typical for insurance companies to require prior authorization for these medications to make sure they’re being used the right way. That means your doctor has to get approval for the prescription before the pharmacy can fill it. Insurance company requirements often include:
- Proof that you have the type of cancer the drug is approved to treat
- A limit on the amount of medication you can get at one time
- Evidence that lower-cost medications haven’t helped
A specialty pharmacy generally knows the insurance plan rules and can get the necessary information from your doctor.
Drug tiers
Prescription drug plans generally divide medications into tiers based on how costly they are. Drugs you get from a specialty pharmacy are usually in the highest tier. You may be asked to pay a percentage of the price, which can be hundreds or thousands of dollars a month.
The specialty pharmacy knows how your health plan classifies your medication and whether it’s possible to negotiate the price.
Questions to Ask the Pharmacist
As with any prescription, you should make sure you understand exactly how to take and store the medication, and what side effects you can expect. Other questions to ask the specialty pharmacist:
- How long will the insurance approval process take?
- What can I do to lower my out of-pocket-costs?
- When will I receive the medication?
- How do I contact you if I have questions or concerns?
- What side effects qualify as an emergency?
- Will you contact me when it’s time for a refill?
Show Sources
Photo Credit: DigitalVision/Getty Images
SOURCES:
American Cancer Society: “Initial Treatment of Prostate Cancer, by Stage and Risk Group,” “Hormone Therapy for Prostate Cancer.”
National Comprehensive Cancer Network: “NCCN Guidelines for Patients: Advanced-Stage Prostate Cancer.”
OncoLink: “Understanding Your Specialty Pharmacy,” “Resources for More Information: Specialty Pharmacies.”
Patient Advocate Foundation: “What’s So Special About Specialty Pharmacy?”
Zytiga.com.
FDA: “FDA approves abiraterone acetate in combination with prednisone for high-risk metastatic castration-sensitive prostate cancer.”
Teva Pharmaceuticals.
National Cancer Institute: “Hormone Therapy for Prostate Cancer.”
Erleada.com.
Xtandi.com.
Nubeqahcp.com.
CLL Society: “Working with Specialty Pharmacies for Oral Drugs for CLL / SLL.”
American Society of Health-System Pharmacists: “ASHP Survey Finds Growth, Opportunities for Health-System Specialty Pharmacy Services.”
KFF: “Copay Adjustment Programs: What Are They and What Do They Mean for Consumers?”
PAN Foundation: “What are charitable patient assistance foundations?”
U.S. Centers for Medicare and Medicaid Services: “Help with drug costs.”
Boston University Chobanian & Avedisian School of Medicine: “Medical Insurance Coverage for Prostate Cancer.”
