Time-to-Fill: A Standardization Dilemma in Specialty Pharmacy

Specialty pharmacy is in the unique position to help the sickest patients in our society, who otherwise may go unnoticed or untreated.

On a grand scale, the profession helps small populations of people with unique disease states. Measuring how quickly and efficiently a pharmacy is able to provide care is difficult, and needs uniform standards.

The various stakeholders would benefit from a standardized scale to rate how well patients are being taken care of, and specifically measure how long it takes to fill a prescription. By looking at the life cycle of a prescription, and documenting concrete checkpoints throughout the process, specialty pharmacies should be able to better explain expected times to fill a prescription to prescribers, patients, and manufacturers, pharmacy benefits managers (PBM), and health plans.

The steps involved from the time a prescriber orders a medication to the time a patient has the medication administered are numerous, and each comes with sub-steps.

Generally, the steps are as follows:

1. prescription written or authorized electronically at the doctor’s office

2. specialty pharmacy receives order

3. benefits exploration with insurer

4. prior authorization

5. paid claim

6. order fulfilled

7. order shipped

8. patient receipt of medication

9. medication administered.

In step 1, it is not uncommon for a prescriber to send a script, or a patient to drop off the script at a pharmacy that is unable to fill the order. Any number of days may pass between the time the order is prescribed and the time the order reaches a specialty pharmacy with the ability to fill the script.

In step 2, it is up to the specialty pharmacy to manage workflow to ensure a received order is worked on. This may start immediately, or unfortunately, may simply be sent to the end of the queue, where it sits stagnant for hours or days until it reaches the front of the queue.

Step 3, the benefits exploration, involves communication between the pharmacy and the PBM or health plan, depending upon whether the medication is billed through pharmacy or medical benefits. This step may take a few minutes online, or it may take days of back and forth phone calls depending upon a) the type of drug, b) time since drug has been approved, and c) the complexity of therapy regimen.

A newly FDA-approved drug may not hit the formulary for a number of months before it is reviewed by the PBM or health plan. Step 4, the prior authorization, is generally accepted to be universal when it comes to processing specialty drugs.

This step may take days to weeks, depending upon the complexity of paperwork and efficiency of communication with the prescriber’s office to obtain necessary supporting documentation. Prior authorization is generally accepted as a necessary evil in order to manage proper drug utilization, but should be viewed as an opportunity for specialty pharmacies to help streamline processes when working between prescribers’ offices and the benefit managers.

The next step, obtaining a paid claim, is a logical step in the time-to-fill calculation. Sometimes, this may even occur without going through steps 3 and 4. Following a paid claim, the order must be fulfilled by attaching patient-specific labeling to the medication.

This may occur within an hour, or may take a business day, should the medication need to be obtained from the manufacturer or distribution warehouse. The vast majority of specialty pharmacies do not provide access for a patient to come on site and pick up their medication, and as a result, medication will be shipped via UPS, FedEx, USPS, courier, or delivery drivers on staff.

Proximity to an airport or postal hub will affect how long an order will sit at the specialty pharmacy, as well as how long it will take to deliver to the patient or prescriber’s office. It is safe to bet the majority of shipped orders will reach the final destination within 2 business days.

Once the medication is received by the patient, it may be administered according to therapeutic requirements.

Clearly, the process is complex and each step has a number of variables that must be taken into account, and cannot always be predicted when evaluating time-to-fill. Time-to-fill will also be patient-, drug-, and disease state-dependent.

Some patients may want the peace of mind knowing their medication is in the fridge 2 weeks prior to scheduled use, while another patient may request the order arrive no earlier than the day prior to administration. Some drugs may take longer to acquire due to manufacturer production, wholesaler availability, or extensive documentation requirements.

Some products may simply be too cost prohibitive to stock until a prior authorization is granted. Time-to-fill requirements will vary based upon disease states, as well. For example, a pregnant mother may need Makenna 8 weeks out, and it may be inappropriate to fill the order any sooner than 6 weeks after the script is received.

A contrasting example would be that a patient may need an oncolytic agent no less than 4 days after a script is received in order to keep a scheduled appointment with the cancer center where they are being treated.

Clearly, a generic time-to-fill measurement is not one size fits all. Furthermore, the lack of guidance on time-to-fill specificity means that different pharmacies will have different stated times.

Hypothetically, 2 specialty pharmacies may fill identical products in the same amount of time, but because reporting metrics are different, pharmacy A may have a shorter time-to-fill, and a patient could have missed a dose; while pharmacy B would have a longer time-to-fill, yet their patient received the medication without missing a dose.

Ultimately, the patient must receive their medication as quickly and safely as possible. Standardizing measurements across the lifecycle of prescription will help specialty pharmacies demonstrate success in a concrete fashion that patients, prescribers, manufacturers, and payors can rely upon.

About the Author

John Meehan earned his PharmD degree from Duquesne University in 2010. John worked in retail pharmacy in rural North Carolina before transitioning to a clinical pharmacist position at Chartwell PA in Pittsburgh, PA. John is currently enrolled in the Masters of Science in Pharmacy Business Administration (MSPBA) program at the University of Pittsburgh, a 12-month, executive-style graduate education program designed for working professionals striving to be tomorrow’s leaders in the business of medicines.