Breaking Down Barriers: Ensuring Patient Access to Specialty Medications

July 8, 2025

For patients living with complex and chronic conditions, access to specialty medications is more than a convenience; it is a lifeline. However, the reality of obtaining these therapies is often fraught with obstacles. From prior authorization hurdles to geographic isolation, patients encounter a range of barriers that can delay or prevent critical treatments.

At the same time, health systems, specialty pharmacies, and payers are innovating new ways to close these gaps. Understanding the landscape of barriers and the emerging solutions is essential to improving outcomes, streamlining access, and supporting adherence.

Common barriers to access

1. High cost of therapy

Specialty medications are often priced beyond reach for many patients without insurance or assistance. Despite comprising just 1 to 2% of all prescription claims, these therapies accounted for 45% of pharmacy cost growth in 2018 alone.¹ Insurance plans have responded with cost-management strategies like prior authorizations, step therapy, and formularies, but these mechanisms can introduce additional delays and complexity.²

2. Insurance and reimbursement challenges

Formulary restrictions, copay accumulators, and authorization processes frequently interfere with timely access. Providers must navigate complex benefit structures to determine whether a drug falls under a medical or pharmacy benefit, and whether it will be subject to additional controls such as prior authorizations.³

Changes in dose, therapy, or administration route can trigger further administrative steps, leading to delays that may compromise a patient’s health. Prior authorization turnaround times can range from 24 hours to over two weeks, disrupting treatment for patients who require immediate or sequential dosing schedules.⁴

Additionally, insurance changes, such as job transitions, plan redesigns, or copay program exclusions, can create further instability in a patient's therapy.⁵

3. Limited distribution networks

Some manufacturers limit the number of pharmacies authorized to dispense their therapies to ensure safety and consistent patient monitoring. While this model supports tighter clinical oversight, it also restricts access, particularly for patients in regions not serviced by an approved pharmacy.⁶

4. Complex administration requirements

Many specialty therapies require specific handling, storage, and administration, often involving subcutaneous, intravenous (IV), or intramuscular (IM) delivery. IV and IM drugs, in particular, require professional administration, frequently necessitating travel to an infusion center or clinic. These added requirements can pose serious access barriers for patients with limited transportation or financial means.⁷

5. Geographic barriers

Patients living in rural or underserved areas often face a combination of challenges: fewer specialty-trained providers, limited local pharmacies, and restricted access to infusion centers. This can result in long travel times for each dose or consultation, reducing adherence and complicating care coordination.⁸

Key facilitators to improve access

1. Telehealth and digital health solutions

The growing use of telehealth has been a game changer in expanding access to specialty pharmacy services. Pharmacists can now conduct virtual consults, medication reviews, adherence support, and education without requiring in-person visits.⁹

2. Patient assistance and copay support programs

Many pharmaceutical manufacturers offer copay support or free drug programs to help eligible patients obtain high-cost therapies. These resources are often essential to bridging affordability gaps. For example, an estimated 25% of patients with multiple sclerosis access their medication through payment assistance programs.³

3. Integrated care models

Health care systems that integrate specialty pharmacy services into their broader care delivery model can streamline patient experiences and reduce fragmentation. These models facilitate smoother transitions of care, better coordination among providers, and more efficient communication with payers.²

4. Expanded community pharmacy services

As demand for specialty medications increases, some community pharmacies are adopting specialty pharmacy capabilities. This hybrid model allows patients to pick up both standard and specialty prescriptions from a single location, simplifying care while maintaining clinical oversight.⁹

5. Policy and regulatory shifts

Federal and state policy changes, such as expanded telehealth reimbursement, biosimilar promotion, and REMS (Risk Evaluation and Mitigation Strategies) simplification, are helping improve patient access to high-cost, high-risk medications.¹⁰ Additionally, organizations like the National Association of Specialty Pharmacy (NASP) are advocating for policies that promote equitable access and strengthen specialty pharmacy infrastructure.¹¹

Conclusion

Improving access to specialty medications is a shared responsibility across providers, payers, policymakers, and pharmacy teams. By addressing known barriers and embracing innovative solutions, the health care system can better serve patients in need of these critical therapies.

Whether through enhanced digital access, integrated care coordination, or streamlined reimbursement models, every improvement makes a difference. As specialty drug development continues to grow, staying ahead of access challenges will remain a central focus for organizations across the managed care spectrum.

Let’s bridge the gap together

At PerformRx, we understand the complexities of specialty medication access. Our integrated pharmacy benefit management solutions are designed to break down barriers, support providers, and ensure patients get the treatments they need, when they need them.

Partner with us to streamline prior authorizations, enhance specialty pharmacy coordination, and build access strategies that improve outcomes while managing cost. Connect with our team at info@performrx.com to learn how PerformRx can support your organization's specialty medication goals.

Sign up today to receive strategic insights, industry updates, and thought leadership from PerformRx. Stay informed on how we're improving patient access and delivering pharmacy solutions that drive better outcomes across the health care landscape.

References

1. Erica Conroy, "Specialty Access Barriers: How Technology Can Help," Pharmaceutical Commerce, Vol. 16, No. 1, March 18, 2021, https://www.pharmaceuticalcommerce.com/view/specialty-access-barriers-how-technology-can-help
2. Autumn Zuckerman et al., "An Integrated Health-System Specialty Pharmacy Model for Coordinating Transitions of Care: Specialty Medication Challenges and Specialty Pharmacist Opportunities," Pharmacy (Basel), Vol. 7 No. 163, December 3, 2019, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6958321/
3. Kristina Simacek, et al., "The Impact of Disease-Modifying Therapy Access Barriers on People With Multiple Sclerosis: Mixed-Methods Study," J Med Internet Res., Vol. 20, No. 10, October 30, 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6234348/?report=classic
4. "2024 Prior Authorization State Law Chart," American Medical Association, https://www.ama-assn.org/system/files/prior-authorization-state-law-chart.pdf
5. "Health Equity in Telehealth," Health Resources and Services Administration, https://telehealth.hhs.gov/providers/health-equity-in-telehealth
6. Alex Toman, "Why Limited Distribution in Specialty Pharmacy?" Pharmacy Times, April 27, 2018, https://www.pharmacytimes.com/view/why-limited-distribution-in-specialty-pharmacy
7. "Rural Pharmacy and Prescription Drugs Overview," Rural Health Information Hub, March 7, 2025, https://www.ruralhealthinfo.org/topics/pharmacy-and-prescription-drugs
8. Michael Piskuric, "Telemedicine Provides Paradigm Shift in Specialty Pharmacists' Role on the Care Team," Pharmacy Practice in Focus: Oncology, Vo. 5, No. 3, April 13, 2023, https://www.pharmacytimes.com/view/telemedicine-provides-paradigm-shift-in-specialty-pharmacists-role-on-the-care-team
9. Alex Miguel, "Community Pharmacies Expand Services with Specialty Pharmacy," Outcomes, December 23, 2020, https://www.outcomes.com/blog/pharmacy/specialty-pharmacy-services
10. S.B. Russek, "Specialty Pharmacy’s Role in REMS," Formulary Watch, October 1, 2009, https://www.formularywatch.com/view/specialty-pharmacys-role-rems-fdas-new-drug-safety-program
11. "About NASP," NASP, https://naspnet.org/about