Configure a specialty pharmacy hub service to receive and process patient enrollment referrals from a pharmaceutical manufacturer's patient support program

Steps

1. Establish a data exchange agreement with the manufacturer's hub (or operate as the hub); define the patient referral data format—commonly HL7 v2.x ADT/ORM or a manufacturer-defined flat file/JSON schema transmitted via SFTP or HTTPS API
2. Receive the patient enrollment record: capture patient demographics, prescriber NPI, drug product (NDC or J-code for specialty/biologics), diagnosis code (ICD-10), insurance information, and consent/HIPAA authorization status
3. Perform benefits investigation (BI): submit eligibility queries to commercial and government payers; document coverage tier, PA requirements, specialty pharmacy network requirements, and estimated patient out-of-pocket cost
4. If PA is required, initiate the PA workflow via CoverMyMeds or NCPDP SCRIPT 2017071 ePA; track PA status and update the hub system record; notify the prescriber and patient of PA outcome
5. Once PA is approved and specialty pharmacy is confirmed, transmit a referral/prescription to the specialty pharmacy using NCPDP SCRIPT NewRx or a proprietary hub-to-pharmacy data exchange; include PA number, hub case number, and any manufacturer financial assistance (copay card) details
6. Generate dispense status and adherence reports back to the manufacturer per the data-sharing agreement (typically de-identified or aggregated per HIPAA); use SP data aggregator networks or direct SFTP reporting as agreed