Steph’s Note: This week, we welcome a new voice to tl;dr. Say a virtual hi to Vaidehi Parekh, PharmD! Vaidehi currently works as a Senior Clinical Consultant for a healthcare technology company. She completed a PGY1 Community Practice Pharmacy Residency for a large chain pharmacy, and she previously worked as a lead pharmacist at a PBM-owned specialty pharmacy. Her interests include reading (bookstagram @prescriptiontoread), learning how to create latte art, and cooking. Needless to say, we definitely want to hear what she has to say with her experience and variety of outpatient perspectives!

So if you’re wondering what kinds of careers you can pursue with your PharmD outside of hospital or retail, be sure to read this (and also check out this previous post about working in Industry).

Raise your hand if you’ve been personally victimized by pharmacy school into thinking that your only career options are hospital or retail.

Also raise your hand if you keep hearing people say, “You can do so much more with your degree than hospital or retail!” But you have no idea what said options are…

Some options like ambulatory care might be more obvious since it’s a required APPE, but what about the not-so-obvious ones?

Here are a few that come to the top of my mind:

Specialty pharmacy
Industry/Pharma
PBM (Pharmacy Benefits Manager)
Long term care
Mail order
Clinical consulting

And the list goes on…

There’s a lot to learn about all of the different career paths and which one is right for you. But finding information can be hard, especially when you’re already exhausted from 24/7 studying. So let me alleviate some of the burden by giving you the scoop on specialty pharmacy.

What is specialty pharmacy?

Specialty pharmacy has been a steadily growing sector of the field. Some might even say it’s the future of pharmacy.

A bold statement, I know, but get this. If you do a quick search of what’s in the R&D pipeline for pharma and their recent approvals, you’ll primarily see specialty medications. Additionally, specialty pharmacy is expected to grow 8% per year through 2025 - 8 PERCENT PER YEAR! That’s huge!!

All this leads us to the question: what is specialty pharmacy?

In my past life, I worked at a large PBM-owned specialty pharmacy, and before that, I did my residency at a community-based program with a heavy focus on specialty pharmacy. So knowing that I have a couple perspectives on the field, here are a few ways that I like to describe specialty depending on the audience:

the tl;dr

Expensive medications to treat complex disease states that have few effective treatment options.*
*The only exception is the OG of specialty pharmacy, oncology.

Formal definition

According to the American Pharmacists Association (APhA), “Specialty pharmacy focuses on high cost, high touch medication therapy for patients with complex disease states.”

Friends/family with no pharmacy knowledge

“You know those drug commercials you see when you’re watching TV? The drugs that have weirder than usual names and a laundry list of side effects? That’s specialty pharmacy.”

Pharmacists/other HCPs

You know when you get to the end of a therapeutics lecture and the professor tells you about all the biologics that are basically last line therapy and says, “You’ll likely never see these in practice”? Yeah, that’s specialty pharmacy.

What’s it like to work in specialty pharmacy?

Now you know what specialty pharmacy is, so from here on out I am going to abbreviate it as SP because typing out specialty pharmacy so many times is getting old. And Word keeps wanting to auto-correct specialty to especially.

So next question…where do specialty pharmacists work?

Retail chain SP
PBM-owned SP
Health system SP

These are the options I know of from my experience in the specialty realm, and all three provide very different experiences within specialty. FYI, I went from working at a retail chain local SP that only serviced the surrounding community to a PBM-owned SP, and it was a world of difference (as we’ll talk through in a minute).. But really, at the end of the day, where you want to work boils down to the type of experience you want to have.

Working in a Retail Chain Specialty Pharmacy

Starting with the first option and a slight disclaimer… Each retail chain SP operates just a little bit differently even within the same overarching company, so my experiences might vary a bit from someone else.

That being said, in my case, the retail chain SP was an open door pharmacy (meaning patients could physically walk in like a regular pharmacy) but offered free delivery. This isn’t always the case for SP - many are closed door, meaning patients aren’t able to just walk in and pick up scripts. Many operate as shipping centers only.

So even though the interpersonal opportunity existed, I never saw 99% of our patients in person. BUT I had talked to nearly all of them! I personally had touch points at every step of the process from the time the prescription came to us to the time it left the pharmacy packaged up and ready to go to the patient, including…

Working closely with the provider’s office to make sure the prescription was appropriate,
Assisting with getting an approved prior authorization from insurance,
Obtaining a full medication list from the patient,
Offering financial assistance options if needed, including enrolling the patient for copay cards, patient assistance programs, or foundational assistance,
Counseling the patient on the medication and their disease state, and
Coordinating medication delivery.
For refills, I ensured that the patient was responding appropriately to their therapy (decreased LDL for PCSK9 inhibitors, decreased migraine days for injectable CGRPs, decreased viral load for HIV patients, etc.)

*live footage of me being bright-eyed and bushy-tailed, ready to take on a new role

That was my experience with retail chain SP. Then I decided that the world was my oyster, and I wanted to gain new experiences. So I moved over to a PBM-owned SP.

Working for a PBM-Owned Specialty Pharmacy

When I tell you I was in for an absolute shock… PHEW.

Remember when I said that I used to be in control of everything with every prescription when I was in retail chain SP? Well, there is no way to do that at a PBM-owned SP because they serve all 50 states and US territories. There are SO MANY prescriptions flowing in and out of there that it’s literally impossible.

Before I get into the weeds, let me backtrack and explain why. PBMs that have their own SPs essentially mandate that patients who have their insurance must use their SP for any specialty medication needs. On top of that, there are contracts with other insurance companies where the PBM SP is the preferred SP.

Stay with me here.

Think of all the people in the US with PBM X’s insurance. They all have to use PBM X’s SP. Now think of all the people in the US with Y insurance. The insurance itself isn’t associated with PBM X, but Y insurance company contracted with PBM X so their patients have to use PBM X’s SP if they need specialty medications.

That’s a lot of people.

Now that we’re on the same page, imagine me virtually strolling into work at a PBM-owned SP…not consciously thinking about the sheer volume that goes through the place. I had to do a total mind-shift to adjust to the differences in the work environment.

In my experience, PBM-owned SPs often organize their pharmacists into singular work areas before eventually cross-training them in others. What this means is that you may be responsible for - and only have information about - one piece of the prescription process pie.

For me, I had to develop the mentality that some things were just plain out of my control; otherwise, I wouldn’t have been able to do my job. I had to trust that, after the prescription left my computer screen, everyone else who touched it would make sure the patient was taken care of. Now I am incredibly type A (I’m a pharmacist after all!), so having to turn off the part of my brain that wanted to control everything from start to finish was very hard - especially after my previous retail chain SP experiences.

If I could summarize my wishlist for how to improve a PBM-owned SP’s workflow for both pharmacist and patient satisfaction, it would look like this:

Improve documentation to make it easier for everyone that touches the prescription to have a clearer picture of what has happened.

Because there are so many different people touching a single prescription from receipt to dispensing, it’s essential for those teams to communicate clearly!
If a patient calls and asks why there is a delay with their prescription, any employee they speak with should be able to easily locate the chart notes, determine the cause for the delay, and relay accurate information to the patient. It should not require multiple call transfers.

If a pharmacist obtains clarification on a prescription from the doctor’s office, that same pharmacist should be equipped with the tools and training to immediately take the appropriate follow-up actions to keep the prescription moving.
- In current state, that prescription often has to return to the pharmacist verification queue for a different pharmacist to process, which is just inefficient!

While there are certainly reasons for the way PBM-owned SPs organize their pharmacy staff, namely the ginormous volume of prescriptions coming through, I think these 2 suggestions alone could make a huge difference in combating some of the inefficiencies caused by the siloed workflow model.

Even though you’ve probably noticed I have some frustrations from my time with a PBM-owned SP, I promise there were positive aspects too! I was able to cultivate some unique skills because I had opportunities to do things outside of the traditional pharmacist role. I worked on various projects that involved collaboration with other, non-pharmacy, departments. I continued developing my public speaking and presentation skills by training multiple groups of pharmacists in a variety of different work areas. And while I didn’t have any direct reports, I was a team lead and learned a lot about people management.

That only leaves health system SP. I don’t have any personal experience in it, but guess what - Steph does! So here’s the rundown on her experiences in a health system SP role, in her own words.

Working in a Health System Specialty Pharmacy

Within the realm of health system SP, there are many different roles for pharmacists. Obviously, there’s the traditional, operational side of the gig, in which prescriptions have to be processed for claim approval, verified for clinical appropriateness, dispensed by a technician, checked by a pharmacist, and shipped to patients. (We were a closed door SP, so patients were not able to come to the pharmacy to pick up medications.) So certainly, one can fill the essential role of physically getting medication to patients.

But this is just the tip of the iceberg!

Just like hospital pharmacies seek accreditation from The Joint Commission to demonstrate quality patient care, SPs also often seek accreditation. One of the most popular accreditations for SPs is from URAC (pronounced you-rack), which stands for the Utilization Review Accreditation Commission. Check out the below summary of URAC’s SP accreditation standards:

Notice how much of this chart goes above and beyond the typical dispensing pharmacy. That’s because we’re talking about specialty medications - remember, high cost, high touch, and complex diseases. They require quite a bit more intense effort than the average lisinopril script! Now imagine trying to accomplish these additional responsibilities in a normal dispensing environment…there’s just no way to squeeze that much time out of a day.

^^All my retail pharmacy friends if asked to do a complete medication reconciliation on every new fill prescription. I love y’all, stay strong!!

So to help accomplish the additional care, our health system SP had centralized pharmacists who were in charge of contacting every new specialty medication patient to complete a medication history, discuss their disease state, and thoroughly counsel on the medication before it left the pharmacy.

And I’m not just talking like here are your top 3 counseling points to remember for this med. I’m talking darn near a monograph - not to mention highly specific injection training for all those people new to injectables!

These pharmacists impressed me to no end. Their depth of knowledge about ridiculously complex medications for such a wide range of conditions (I mean everything from psoriasis to migraines to hyperlipidemia to some random inherited hematologic condition, etc) was basically superhuman. Plus they had the ability to break it down and form positive relationships with their patients over the long haul.

When I say long term patient relationships, that’s because not only did they do first fill counseling for these medications, but they also scheduled follow up phone calls in 1 month, 3 months, 6 months, etc. to see about any medication changes and how patients were managing with their therapies. Had they seen improvement? Were they able to have the monitoring labs completed on schedule, and if not, how could they help in getting them done? Any adverse effects? If there were issues, they helped the patient navigate through them or contacted the provider for additional input.

And they documented EVERYTHING. Which in and of itself was a mountain of a task.

In our health system, we also had decentralized pharmacists umbrella’d under the SP, which was the role that I filled. I was a specialty pharmacist deployed to the neuroimmunology clinic along with my technician teammate. Together, we managed our patients’ SP prescriptions from start to finish - and beyond… because there really is never a “finish” with specialty medications. They’re not exactly a set and forget until next year kind of deal.

So what did this look like?

The providers contacted me when a patient was ready to start a new therapy (or if the patient wanted additional follow up discussions when deciding between a couple of therapies). They would enter in the baseline lab orders needed for starting one of these specialty medications, which I would then track and review the results for in order to determine clinical appropriateness and clearance.

If there was an issue on one of the lab results or something was missing, I navigated with the provider, patient, and lab location to ensure the lab was completed. My (absolutely wonderful!) technician started the insurance prior authorization during this time as well and communicated with me about any cost or rejection issues, as well as which specialty pharmacy the patient was required to use for fulfillment based on insurance plans.

Once the patient was medically cleared for therapy (and was comfortable with their medication decision based on our discussions), my technician and I began the process of tackling affordability. For me, this meant anything from writing letters of medical necessity for rejected prior authorizations to enrolling the patient in manufacturer support programs, copay assistance, free drug programs, and/or foundation assistance programs. Only when we had an approved AND affordable medication option to which the patient agreed did we send the script to the filling pharmacy.

Often what it felt like trying to get all the pieces of the specialty prescription puzzle in place.

Then it was a matter of tracking and playing tag with manufacturer support programs, specialty pharmacies, and patients. Once I knew the medication was being shipped (or had been received) from the SP, I called the patients to complete an initial counseling, along with injection training when needed. Some medications required in-home monitoring for the first dose, so there was coordination and follow up for that as well.

Because of the disease states covered by my clinic, I also dealt a lot with infusions, both on site at our health system as well as off site throughout the state for patients who were unable to make it to us. So I spent time collating information to send elsewhere (e.g., orders and referrals), following up on insurance and scheduling, ensuring medication availability (not every site has access to all specialty medications), and reviewing infusion tolerance.

Trust me when I say there were a LOT of spreadsheets.

As pharmacists, we’re also often first-line access points for patients, which means we get to field the questions about infusion bills…yaaaaay. So there was also quite a bit of coordinating with our billing department so patients could get the needed answers (or apply for financial assistance!).

Otherwise, it was a mish-mash of pretty much anything you can imagine. Just some of the things I encountered on a daily basis… Patients calling about running out of meds, not being able to afford their insane copays anymore, being scared of injections, or having medication or injection reactions. I answered drug information questions from providers, was a liaison with drug company support programs and medical science liaisons, tracked and followed up on labs and vaccines, and coordinated with infusion centers about renewing orders or modifying pre-medications.

There’s so much more I could write, but I feel like I’m already bordering on losing the “tl;dr” sentiment.

So I’ll just say that, although I was often frustrated with the amount of time I spent listening to an SP’s hold music to get answers about a patient’s prescription (^^see Vaidehi’s earlier notes on PBM-owned SP silos) or how many months (yes…MONTHS) it could take to get a patient actually started on therapy after their clinic visit, I more frequently was overwhelmingly fulfilled knowing I was helping patients obtain and understand their very complex therapies.

I built longitudinal relationships not only with my patients but also with my providers, my technician, other health systems, MSLs, Pharma, and others! I’m grateful for the organization, project management, and communication skills I refined, as well as a broader understanding of health care and insurance as a whole. I wouldn’t trade this experience for anything.

And I almost forgot the best part about specialty pharmacy… No residency required!*
*With the potential exception of oncology. Also, just because it’s not required doesn’t mean you can’t or shouldn’t. I did a residency with a specialty focus because I wanted to be a more competitive candidate in a very saturated local market.

Thanks, Steph, for that perspective on health system SP!

The tl;dr of Specialty Pharmacy

Now you hopefully have a clearer picture of a career path you can take outside of hospital or retail!

Specialty medications are high cost, high touch medications for complex disease states. There is typically more intense management for both the provider and the pharmacy for patients on specialty meds, which provides for many pharmacist job opportunities.

There are 3 main options for working in specialty pharmacy, and they each provide different experiences:

Retail chain SP
PBM-owned SP
Health system SP

As a student, it may be difficult to find an intern position at a specialty pharmacy because they typically do not hire part time and their operating hours are usually weekdays 8am-5pm. But with the 315% growth in specialty pharmacies from 2015 to 2021, your school might have an elective about specialty pharmacy or offer APPE rotations at SPs.

Take advantage of those opportunities to learn more and see if you like SP! Check out where some of your pharmacy school alum work because I bet a surprising amount have gone into specialty. You might be able to gain additional perspective from them or perhaps even a shadowing experience.

So welcome to the wonderful world of specialty pharmacy! Come on in and get your feet wet!!

Career Options for Pharmacists in Specialty Pharmacy