Specialty Pharmacy vs. Specialty PBMs: What’s the Difference?
A Payer’s Guide to understanding the differences between Specialty Pharmacies and Specialty PBMs
Why This Matters
Specialty medications are reshaping the economics of pharmacy benefits. These high-cost therapies, often used to treat complex, chronic, or rare conditions, now account for 54% of total spending, up from 49% in 2018 (IQVIA).
As specialty spend continues to rise, so does the complexity of managing it. It’s critical for health plans and plan sponsors to clearly understand the two key players behind the scenes: Specialty Pharmacies and Specialty Pharmacy Benefit Managers (PBMs).
Both play a pivotal role in how specialty drugs are accessed and paid for, yet they serve fundamentally different purposes. In this article, we’ll break down the distinctions between specialty pharmacies and specialty PBMs, explain how the two interact, and outline the value that specialty PBMs bring to Payers.
What is a PBM?
At its core, a Pharmacy Benefit Manager (PBM) administers prescription drug benefits on behalf of Payers and employers. PBMs manage everything from formulary design and pharmacy networks to claims adjudication, utilization review, and clinical programs that influence prescribing and cost trends.
A Specialty PBM is designed to manage the unique challenges that come with high-cost, high-complexity medications that are used to treat serious conditions like cancer, autoimmune disorders, or multiple sclerosis. These therapies often involve intricate distribution requirements, intensive clinical oversight, and careful financial management. By focusing solely on this category of drugs, specialty PBMs provide the infrastructure and expertise needed to guide appropriate use, control costs, and support better outcomes for both patients and Payers.
What is a Specialty Pharmacy?
A Specialty Pharmacy is a dispensing entity that provides medications and direct support to patients dealing with complex medical conditions. These pharmacies are equipped to:
- Deliver medications that require special handling or cold chain storage
- Educate patients on proper use and side effect management
- Support adherence through ongoing engagement
- Assist with prior authorizations and copay programs
Unlike a specialty PBM, which operates at the plan sponsor level, specialty pharmacies work directly with patients and prescribers to ensure therapies are delivered and managed appropriately at the individual level.
Key Differences and the Collaborative Roles of Specialty PBMs and Specialty Pharmacies
While both specialty pharmacies and specialty PBMs operate within the specialty drug ecosystem, their roles, responsibilities, and value to Payers are distinct. Specialty pharmacies focus on dispensing medications and supporting patients directly, while specialty PBMs manage the broader benefit design, contracting, and cost controls behind the scenes. Specialty PBMs work directly with Specialty pharmacies by including them their pharmacy network.
Understanding how they differ, and how they work together, is essential for any Payer looking to optimize specialty drug strategies.
| Primary Role | Dispenses specialty medications and supports patients | Manages specialty drug benefits for health plans/plan sponsors |
| Core Functions | Dispensing, patient education, adherence and side effect management, prior authorization support | Benefit design, formulary management, contracting and rebate negotiation, utilization management, data and reporting |
| Customer | Patients, prescribers | Health plans, plan sponsors |
| Network Scope | Single pharmacy | Can support multiple specialty pharmacies |
| Clinical Support | High-touch, one-to-one patient engagement | Sets clinical protocols, monitors population-level outcomes |
| Financial Role | May offer assistance with manufacturer copay programs | Controls overall specialty spend, offers copay and patient assistance program support |
While their roles differ, specialty PBMs and specialty pharmacies are deeply interconnected. They work in tandem to manage the clinical, logistical, and financial complexities of specialty drugs. Specialty PBMs develop and administer benefit designs for high-cost therapies, establishing policies around utilization, prior authorization, and network participation.
This structure allows PBMs to ensure the most cost-effective and clinically appropriate treatments are delivered, while pharmacies focus on member-level execution. Payers benefit from coordinated care delivery without losing control over drug spend.
Why Payers Should Consider a Specialty PBM
As specialty medications grow more expensive and complex, many traditional PBMs struggle to keep pace with the specialized oversight required. That’s where a specialty PBM delivers real, measurable value to Payers:
- Focused Clinical Expertise: Specialty PBMs are built around managing serious, complex conditions. Their clinical teams understand the nuances of therapies like biologics and gene treatments and can apply evidence-based protocols to guide coverage and steerage decisions.
- Cost Savings Through Smarter Contracting: With a narrower focus, specialty PBMs can often negotiate more favorable contracts, rebates, and reimbursement rates, helping Payers lower their total cost of specialty drug spend.
- Utilization Insight and Member Steerage: Specialty PBMs track how medications are used across populations and can direct members to higher-value, clinically appropriate alternatives. This is especially important as new specialty therapies enter the market at a rapid pace.
- Flexibility Across Multiple Specialty Pharmacies: Rather than relying on a single dispensing pharmacy, specialty PBMs can triage across multiple pharmacies, ensuring the right medication is delivered from the most effective source. Even if a health plan or its PBM already works with a specialty pharmacy, it may still be missing the strategic oversight a specialty PBM provides.
How MacroHealth Supports Payers and Specialty PBMs
Managing pharmacy spend, including specialty drug benefits, requires making smarter, more strategic decisions across an increasingly complex marketplace.
The MacroHealth Intelligent Exchange (MiX™) platform supports Payers in optimizing pharmacy spend holistically, connecting them with high-value partners including specialty PBMs who excel in cost control, clinical performance, and flexible contracting.
By providing transparent insights into performance and enabling evaluation across the full pharmacy landscape, the MiX platform helps health plans and employers design more competitive, effective benefits, whether they are refining their specialty PBM strategy or managing pharmacy spend as a whole.
Ready to explore how MacroHealth’s Pharmacy Solutions can help you gain control, reduce costs, and optimize your entire pharmacy portfolio?