Specialty Pharmacy Access

Specialty pharmacy access strategy, from network access to referral-to-fill

Limited-distribution and payer network access, referral-to-fill capture, accreditation, and 340B-enabled contract pharmacy design. Where capture is leaking we find it. Where the network is closed we map what it would take to open it.

What this covers

Work here is scoped to what you are trying to change: capture, access, accreditation, or all three.

Network and limited-distribution access

A clear read on which doors are open, which are closed, and what each one would take.

  • Limited-distribution drug network access strategy
  • Payer and PBM network participation review
  • Manufacturer access criteria and data requirements
  • Realistic sequencing of which networks to pursue first

Referral-to-fill capture

Internal capture is the fastest available lever and usually the least measured.

  • Referral routing and capture rate by clinic and class
  • Leakage analysis against external specialty pharmacies
  • Triage, transfer, and re-routing workflow
  • Fill, refill, and adherence follow-up design

Accreditation and quality

The roadmap, the evidence, and who owns each element, without an eighteen-month detour.

  • URAC and ACHC accreditation roadmap and gap analysis
  • Policy, procedure, and quality program build
  • Patient management program design
  • Survey preparation and mock review

340B-enabled contract pharmacy design

Program design that supports patient access and holds up under a HRSA audit.

  • Contract pharmacy structure and TPA configuration
  • Qualification logic and documentation standards
  • Duplicate discount prevention
  • Performance and reconciliation oversight

Feasibility and operating model

Before the buildout: whether the math works, and what it takes if it does.

  • Feasibility and pro forma reality check
  • Operating model, staffing, and technology design
  • Revenue cycle integration
  • Payer and PBM contracting strategy

Performance measurement

The operating metrics that tell you whether the program is working this month, not next year.

  • Capture rate, time-to-fill, and turnaround
  • Prior authorization approval and denial trending
  • Abandonment and first-fill completion
  • Margin and mix by therapeutic class

What you get

Deliverables are short by design. The test is whether your team can run them after I leave.

Deliverables

  • A capture and leakage baseline by clinic, class, and payer
  • A network access strategy with realistic sequencing and effort estimates
  • An accreditation roadmap with gap list and owners, where accreditation is in scope
  • An operating scorecard your team runs monthly

When people call

  • Referrals are leaving the system and nobody can quantify how many
  • You are building or scaling a specialty pharmacy and need the math checked first
  • Accreditation is coming and the gap list has never been formally written
  • A limited-distribution network denied access and you need to know why
  • Contract pharmacy performance changed and the reason is not obvious

Start with a 30-minute call

Bring the audit finding, the number that is not adding up, or the workflow that keeps stalling. If I can help I will tell you how. If I cannot, I will point you to someone who can.