Does Formulary Contracting = Patients Will Get Their Prescriptions?

By Dan Rubin, CEO

When considering whether a health plan will actually pay for a pharmaceutical product that has been prescribed for a patient, it is important to understand that a product that is “covered” under contracts with the various plans and pharmacy benefit managers (PBMs) may not be readily available to their insured patient members.  All too often, it is difficult for patients to obtain a product that is covered by insurers and PBMs because of the imposition of prior authorization (PA) requirements, which have practical, real-world implications for health care providers and their staff.

As a case in point, a product manager recently stated that “we don’t have a PA problem, since we are under contract with 96% of the marketplace.” While there is some comfort in being on the approved formulary for a health plan or PBM, providers may still face significant market access restrictions when they prescribe the product, often resulting in lost product sales.

Being under contract means that a manufacturer has negotiated a position on the plan’s formulary, which no doubt is better than “Product Not Covered” or “Benefit Exclusion.”  However, with multi-tiered formularies being the norm today, branded products will more likely be placed in a second, third or more undesirable tier position, which will prompt a prior authorization or step edit before the plan or PBM adjudicators will pay for the medication.

PA is the requirement by a patient’s pharmacy benefit plan that providers must seek – and get – approval before a prescription product can be reimbursed for dispensing.  In many instances, this requires that the provider enter specific clinical information or test results justifying the PA request and/or provide confirmation that one or more preferred formulary alternatives have been tried.

[see the article on PharmExec.com for real-life example, additional details]

From the perspective of a pharmaceutical brand, there are factors to keep in mind; For brand teams and product managers, it is critical to think about PA requirements from the provider’s point of view:

  • Look closely at what your product’s contract status really means. If the product is covered on formulary, what tier is it on? What are the specific PA requirements for that tier?  Are the PA requirements similar or different across plans?
  • What is the PA burden that the practice faces from the perspective of both the prescriber and the office staff who usually process PA requests? Is a PA required in all or most cases?  What are the key criteria for approval?
  • What percent of prescriptions that are denied at the pharmacy because of PA requirements end up being filled as prescribed? Based on data from both pharmacy and electronic medical records, the percentage is often in single or low double digits.  How can you identify those practices with potential to improve their support of PAs?
  • How can practices be motivated to submit PA requests? How can your product investment effectively support practices to efficiently process PAs in terms of ease of submission, follow up with the PBM, updates on PA status, handling of requests for additional information, and support of appeals?

Product contracting for pharmaceutical products is important, but it is usually not sufficient by itself to assure broad market access.  In some ways, it can be likened to buying a ticket to a major sporting event – it does get you inside the doors of the arena, but the price can be high (think rebates) and you might be up in the rafters and maybe have an obstructed view. If you can see the scoreboard at all, it may not show the results that you desire.

The above is excerpted from an article by Dan Rubin, President and CEO, PARx Solutions, appearing on PharmExec.com. To read the complete article, please go to: http://www.pharmexec.com/does-formulary-contracting-patients-will-get-their-prescriptions.

“Set it and forget it” – keeping patients on the Rx their provider prefers

By Dan Rubin, CEO

Several years ago, while bored on a Saturday afternoon, I was “channel surfing” on my television and saw an infomercial for a rotisserie oven.  The spokesperson, Ron Popeil, repeatedly used the tag line, “just set it and forget it” to show how easy it was.  While “set it and forget it” may work when making rotisserie chicken, it does not usually get the job done when it comes to prescription prior authorizations (PA).

pharmacy-pa-problemsProviders may go through the process of completing and submitting a PA when writing the initial new prescription (NRx) for a patient.  However, most PAs are approved by the plan for twelve months or less.  If the prescriber has written a medication for chronic conditions, this means that the patient will not get coverage after the PA expires unless a second PA is submitted.  For many of these patients, it is appropriate to continue therapy for several years.  At PARx, we have found that providers resubmit PAs for their patients upon expiration only 5 or 6 percent of the time.  This presents a tremendous opportunity for patients, providers, and pharma brands.

Earlier this year, PARx launched our reauthorization program.  For interested sponsors, PARx provides notifications to providers a few weeks prior to a PA expiration.  The notification informs the provider that a PA has been initiated in the PARx PASS system and directs the provider to complete and submit the partially completed PA.  By making the reauthorization process simple for providers, this new program has produced spectacular results to date:

  • Upon receiving notification from PARx of the expiring PA, 50-60% of providers resubmit a PA request.
  • The PA approval rate for these second submissions is averaging 96 percent. Compared to the 5-6% submission rate without notification, this program creates thousands of additional prescriptions for our sponsor brands.
  • More importantly, patients are able to continue on their chronic therapy without interruption.

When it comes to PA, providers who work with PARx can “set it and forget it,” thanks to a timely renewal reminder – and rest easy knowing their patients will continue to have access to the Rx they deem best for their treatment.

Death by Prior Authorization

Pharmaceutical Executive | Dan Rubin | April 24, 2019

I recently read news that really brought home the real-life impact on patient care —really, on patient’s lives—of an effective prior authorization (PA) process. In February 2019, long-time disability rights activist and attorney Carrie Ann Lucas died prematurely at age 47 from a plethora of health problems, exacerbated by her disabilities.

However, according to a post following her passing on her Facebook page, her friends and family identify the root cause as the denial by her insurance carrier of “the one specific inhaled antibiotic that she really needed. She had to take a less effective drug and had a bad reaction to that drug. Read the full article.

From chaos to clarity: how a PA partner can help practices cut out the confusion

By Dan Rubin, CEO

In the February issue of Primary Care Optometry News, an optometrist who utilizes PARx in his practice was interviewed about his experience with the prior authorization (PA) process – and what best practices he would recommend. “Prior authorizations are here to stay,” Jeffrey S. Williams Jr., OD, Dipl ABO, noted in the article. “Optometrists must learn how to navigate prior authorizations in order for their patients to receive the branded medications they are prescribed.”

Williams, who practices on Long Island, New York, recommends use of a full-service PA process provider to any medical practice struggling with the challenge of PA. His office uses PARx Solutions.

Before adopting the service, navigating PA in his office was messy, Williams said. “It was a lot of blank forms from the 10 different, respective insurance companies that we accept. You’d have to fill it out, fax it and pray that it was approved. If it wasn’t approved, you’d get a 15-page fax back,” he said.

His staff would manage lengthy spreadsheets to keep track of patients, various dates and follow-up milestones. “It was a lot of wasted time and frustration,” Williams said.

Williams outlined how practice owners can assess the impact of the PA process on their practice and weigh the systems available that are intended to help. He wrote that a good starting point is looking at the individual PA process challenges at the practice. These may include:

  • How often are prescriptions denied coverage because a PA is required?
  • Are your patients’ managed care plans frequently changing the criteria for approving coverage for your prescribed medications?
  • How important is it for your patients to receive the specific medication that you originally prescribed?

Next, he suggested appraising the current burden on the optometrist and staff in managing PAs:

  • How many hours are spent on PAs including: hunting down the correct form, completing and submitting the forms and spending time on the phone with managed care plans?
  • How often are submitted PAs denied by the plan?
  • If denied, how often does your practice appeal the decision with the plan?

Finally, he suggested considering the PA process options: using a form-based service, or ideally, a full-service provider, per his experience with PARx.

Providers also have the option of going it alone, which Williams says may require a member of the staff focusing solely on PAs or carving out time from multiple staff members. After using the service, not only are approvals accomplished faster at his office, but through the experience, his staff has learned many of the protocols for the different insurance requirements.

“It went from chaos and confusion and shooting in the dark to seeing more patients daily,” Williams said of his practice’s transition to full-service PA provider PARx Solutions.

The above is excerpted from an article appearing on Healio.com. To read the complete article, please go to: https://www.healio.com/optometry/therapeutics/news/print/primary-care-optometry-news/%7B62e366db-cf6b-4049-807d-502eec4b17ad%7D/clinicians-provide-best-practices-for-helping-patients-access-medications?page=1

Closing The Loop on Patient Engagement: Overcoming the PA Washout

By Dan Rubin, CEO

As pharmaceutical marketing has evolved from “selling pills” to assuring that medications actually get dispensed and taken by patients, many brands have layered patient engagement and support programs into the marketing mix to assist with a range of issues including patient education, therapeutic support, benefit verification, financial assistance, and adherence support. Many brands utilize a patient support program (sometimes referred to as a “patient hub”) as a single point of contact for patients to access these support services online or via 800 numbers. Beyond receiving general product/condition education prior to therapy initiation, patients frequently use these support programs to verify insurance coverage, understand whether prior authorization is required, obtain co-pay cards, or explore the potential availability of Medicare tier exceptions.

While patient support programs often claim to address patient access issues such as PA, they usually fail to result in high physician submission and approval rates. After performing a patient-specific benefit verification and determining that a PA is required, the typical action is to fax a PA form to the prescriber. Similarly, if the patient is covered by Medicare and might be eligible for a lower co-pay from a tier exception (TE), they typically fax the Medicare Coverage Determination form to the practice. In either case, practices frequently do not follow through on the PA or TE request due to the burdensome submission and follow up process required by the managed care (or Medicare) plan. As a result, the PA doesn’t get submitted and the patient gets switched to an alternative therapy or abandons treatment altogether.

One brand utilized an innovative program to drive more prescriptions by integrating a full-service PA support program based on the result of their benefit investigation. Prior to implementing this new program, the brand reported that physician PA submission rates were very low and when a PA was submitted, approval rates averaged around 50-60 percent.

Results. After implementing the new program, the brand saw significant increases in both PA submission and approval rates. Physicians submitted PAs more than 50 percent of the time after receiving a notification from the service provider. Over 42 weeks, physicians submitted a total of 952 PAs independently (without receiving any notifications). After receiving notifications, physicians submitted an incremental 4,967 PAs, with a 75 percent average approval rate.

Overall, the program resulted in nearly 4,000 incremental approved PAs, which translated into approximately 10,000+ incremental TRx’s. The brand’s return on investment in the program was sixteen to one, and more importantly, approximately 4,000 patients ended up receiving the medication their physician deemed best, instead of a substitute therapy or abandoning therapy altogether.

When left on their own, many practices will not deal with the cumbersome process of completing and submitting PAs. A service that makes this process more streamlined and less time consuming for physicians and their staff will lead to higher PA submission rates and more prescriptions dispensed.

Many pharma brands have already created patient support programs that address patient coverage issues.  Adding an effective PA service can be a small incremental step that yields large benefits from more patients on therapy, less physician frustration, and fewer prescriptions being substituted or abandoned.

The above is excerpted from an article by Dan Rubin, President and CEO, PARx Solutions, appearing on PharmExec.com. To read the complete article, please go to: http://www.pharmexec.com/closing-loop-patient-engagement-overcoming-pa-washout.

Closing The Loop on Patient Engagement: Overcoming the PA Washout

Pharmaceutical Executive | Dan Rubin | September 21, 2018

prescriber-solutions

Pharma brands invest heavily in sales and marketing tactics aimed at convincing physicians to prescribe their product. Even when successful, these efforts represent only a first step in realizing more prescriptions that actually get dispensed. Particularly when a prescription requires prior authorization (PA), retail pharmacy data shows that the originally prescribed product ends up being dispensed less than thirty percent of the time.  In two-thirds of cases, the medication is either switched to another product or abandoned altogether, leaving both patients and physicians frustrated. PA requirements are being implemented by payers for more brands across most therapeutic categories, so the negative impact on pharma continues to deepen. Read the full article