Atopic Dermatitis: Evolving Role of Specialty Pharmacy

Peter L. Salgo, MD: How do the specialty pharmacies prepare to manage treatments for AD, and how would you approach things like understanding these new options and making him [the payer] happy? After all, don’t we all want to make him happy?

Cheryl Allen, BS Pharm, MBA: We all do. As we talk about collaboration of stakeholders, it’s specialty pharmacies working together with payers, working with prescribers really, to make sure that we’re taking care of these patients. Some of these drugs in the atopic dermatitis pipeline may or may not come through specialty pharmacy as a mainstay. Maybe specialty pharmacy is really that backstop. Maybe they’re not limited in their distribution to specialty. Maybe they are out in the open distribution. Probably a topical, I’m not so sure. For injectables, that can be tricky, particularly in this patient population where they’ve not been on an injection prior. Dupilumab will have a loading dose, presumably that will be done in the doctor’s office, so there’s some training on that. But then we need reinforcement of injection site training. That’s a lot of what specialty pharmacy does, right? We educate on the disease state, we educate patients on what they can do, just in general, to take care of themselves. So, there are a lot of things that we are preparing ourselves for in this atopic dermatitis space because, historically, we’ve not been there. We don’t have that segment cut out.

Ed Pezalla, MD, MPH: And Cheryl, one of the things that I think is perhaps not completely unique here, but is really important, is that the patients are going to need to continue these other therapies. So, right now, a lot of the therapies that go through a specialty pharmacy, that’s the entire therapy. They have perhaps one injection for MS and maybe they’re taking Ampyra orally, but you really don’t have to worry about that too much. If they’re benefitting from it, they take it, we know this. But in this case, these patients may be on rather complex topical regimens. They may also need, for at least some period of time, to be taking an oral medication antihistamine or something to take the edge off the pruritus. And so, can a specialty pharmacy help the patient in adherence with those things when they’re not actually the things that you provide? So, you don’t really have any data on it, but you’re going to be talking to the patient.

Cheryl Allen, BS Pharm, MBA: That’s an interesting concept because at Diplomat, we do a great deal of work in the oncology space. And some patients, even though we may only have a limited distribution on one of their drugs, we offer to fill all of their drugs if that’s what the patient would like us to do. Revlimid, for instance, dexamethasone pulse therapy, we offer to fill all of those. In the cystic fibrosis space, we may take that entire patient and fill all of those drugs—digestive enzymes. We may even throw in hand sanitizer and tissues. Again, it’s that concept of taking care of that patient all around. Most of the specialty pharmacies that you’ll deal with also have some type of national accreditation, URAC accreditation or equivalent. And one of those parameters of getting that accreditation is that on an intake, you’re looking at all of those prescription and nonprescription drugs that the patient is on. When we do our counseling with the patients, we understand; again, going back to that 360° view of the patient. So, we know not only that specialty drug that we’re filling, we also know the nonspecialty drugs that we may or may not be filling, even over-the-counter drugs.

Peter L. Salgo, MD: What about working with physicians’ groups?

Cheryl Allen, BS Pharm, MBA: We have to be a resource group to the physicians. Specialty pharmacy is a resource to send out fax notifications on drugs that will be coming available. So, we are the peer resource for that for these folks if they’re willing to talk to us about that.

Peter L. Salgo, MD: I hate to point out that faxes are going away.

Cheryl Allen, BS Pharm, MBA: Oh, interesting that you say that. In 1990, the mode of transmission for prescriptions into specialty pharmacy was fax. Today, it’s the same thing.

Peter L. Salgo, MD: Is that right?

Cheryl Allen, BS Pharm, MBA: And really it’s because from the payer perspective, there’s a lot of clinical information that’s needed to go along with the justification for appropriate utilization. We’ve talked about a lot of that today. Can you imagine writing out the prescription and trying to hit e-submit? But then you need that EASI score, you need the SCORAD, and then you need concomitant therapy. So, there’s a lot of information the prescribing community is sending in those fax forms.

Peter L. Salgo, MD: Okay. They’re not doing e-prescriptions for this kind of stuff. That’s surprising to me.

Cheryl Allen, BS Pharm, MBA: Not on new prescriptions. Some of the refill prescriptions will come in on e-prescribe.