Specialty Pharmacy: How Providers Manage Generic Specialty Drugs

When a patient gets a generic version of a complex medication like methotrexate or etanercept, they might expect to pick it up at their local pharmacy. But that’s not how it works. Even when a specialty drug becomes generic, it often still goes through a specialty pharmacy. Why? Because it’s not about the price tag-it’s about the process.

What Makes a Drug ‘Specialty’?

A specialty drug isn’t just expensive. It’s complicated. These are medications that need special handling: refrigeration, precise dosing, injection or infusion, and close monitoring. Think biologics for rheumatoid arthritis, cancer treatments, or hepatitis C therapies. Even when a generic version becomes available, it doesn’t suddenly become a simple pill you can grab off a shelf.

The FDA doesn’t approve true generics for most biologics. Instead, they approve biosimilars-medications that are highly similar but not identical. These still require the same level of care as the original brand. That’s why the distribution model doesn’t change just because the price drops.

Why Providers Use Specialty Pharmacies for Generics

Manufacturers often lock their drugs-brand or generic-into specialty pharmacy networks. This isn’t a loophole. It’s a requirement. If a drug has a Risk Evaluation and Mitigation Strategy (REMS), only certified specialty pharmacies can dispense it. And most complex medications do.

For example, a generic version of a biologic used to treat Crohn’s disease might cost 30% less than the brand. But if the manufacturer requires REMS compliance, the patient still gets it through a specialty pharmacy. Retail pharmacies aren’t allowed to fill it, even if it’s generic. The law doesn’t care about the price-it cares about the risk.

Providers know this. They don’t choose specialty pharmacies because they like the paperwork. They choose them because they have to. Skipping the specialty channel could mean the patient doesn’t get the drug at all-or worse, gets it without proper training or monitoring.

The Workflow: More Than Just Shipping Pills

Dispensing a generic specialty drug isn’t like filling a prescription for antibiotics. It’s a multi-step operation:

• Prescription intake and verification
• Prior authorization with insurers
• Financial assistance coordination (many patients can’t afford even generics)
• Clinical assessment by a specialty pharmacist
• Training the patient on how to inject or infuse the drug
• Temperature-controlled packaging and shipping
• Follow-up calls to check for side effects

This isn’t optional. A 2023 study found that specialty pharmacies spend an average of 45 minutes per patient on counseling and monitoring-not including the time spent on insurance appeals. That’s 10 times more than a retail pharmacy spends on a typical prescription.

Even when the drug is generic, all these steps stay the same. The patient still needs to know how to store it. Still needs to track side effects. Still needs to get lab tests scheduled. The pharmacy doesn’t cut corners just because the drug is cheaper.

Speed, Cost, and Patient Frustration

There’s a downside. Turnaround time for specialty prescriptions averages 7.2 days. Compare that to retail pharmacies, where most prescriptions are ready in under 2 hours. For patients on tight schedules-especially those with chronic conditions-those extra days matter.

Some patients report sticker shock. One user on Reddit switched from a $15 copay at Walgreens for generic methotrexate to a $75 copay through a specialty pharmacy, even though the drug was the same. Why? Because specialty pharmacies charge dispensing fees-often $250 to $500 per script-billed to the insurer. That cost gets passed down in the form of higher patient copays.

But here’s the twist: patients who stay with the same specialty pharmacy through a brand-to-generic switch report higher satisfaction. A January 2024 survey found 68% of patients preferred keeping their existing care team. Why? Because the nurse who taught them how to inject their drug last year still remembers their name, their anxiety, their schedule. That continuity saves lives.

Who Runs Specialty Pharmacies?

The market is dominated by three giants: OptumRx, CVS Specialty, and Express Scripts. Together, they control 84% of the U.S. specialty pharmacy market. Smaller regional players exist, but they’re often bought out or partnered with health systems.

Health systems are pushing back. In 2024, 63% of surveyed hospitals said they planned to build their own specialty pharmacy operations. Why? Because they’re tired of losing control-and revenue-to outside vendors. If a hospital can dispense a generic specialty drug in-house, they can cut out the middleman, reduce delays, and keep patient data inside their own system.

This shift could change everything. If hospitals start handling their own specialty drugs, the traditional specialty pharmacy model may shrink. But the core services-patient education, monitoring, coordination-won’t disappear. They’ll just move inside the clinic.

The Future: Biosimilars and Technology

Biosimilars are the big growth area. By 2028, they’re expected to make up nearly half of all specialty drug spending. And they all go through specialty pharmacies. The 2024 CMS rule requiring Medicare Part D to cover all FDA-approved biosimilars means more patients will get these drugs-still through specialty channels.

Technology is helping. Real-Time Prescription Benefit (RTPB) systems have cut prior authorization times by over three days. That’s huge. But the human element still matters. A pharmacist who’s trained in rheumatology knows what questions to ask. A care coordinator who’s been with a patient for a year knows when to escalate a side effect.

What Providers Should Know

If you’re a provider prescribing a generic specialty drug:

• Don’t assume the patient can get it at a retail pharmacy. Check the manufacturer’s distribution rules.
• Know the REMS requirements. Some drugs can’t be dispensed without them.
• Explain to patients why they’re going through a specialty pharmacy-even if it’s cheaper. They’ll be less frustrated if they understand the ‘why’.
• Push for continuity. If a patient is switching from brand to generic, keep them with the same pharmacy and care team.
• Watch for delays. If a prescription is stuck in prior auth for over a week, call the pharmacy. Don’t wait for the patient to complain.

The bottom line? Generic doesn’t mean simple. Specialty drugs-whether branded or generic-require a level of care that retail pharmacies aren’t built to provide. Providers aren’t choosing specialty pharmacies because they’re convenient. They’re choosing them because they’re necessary.

What’s Next?

The line between brand and generic is fading in specialty pharmacy. What matters now is the complexity of the drug, the risk to the patient, and the support they need. The next five years will see more biosimilars, more hospital-run pharmacies, and more pressure to cut costs. But the need for trained professionals who understand these drugs won’t go away. It’ll grow.

Patients aren’t buying a pill. They’re buying a system. And that system still needs people.