“It’s pretty exciting to see what the market-based solutions might be,” Dr. Levin said.
But things get more complicated when you add in other requirements. Prior authorizations, for one, have become an increasingly time-consuming process, said Wendy Ramey, BSPharm, RPh, a specialty pharmacist at the University of Kentucky.
“Everything needs prior authorization, it seems,” she said. “I had a prednisone prior authorization last month—believe it or not.”
She, too, discussed concerns about PBMs’ “opaque and complex” rebate arrangements and requiring providers to “choose one medication over another just for the sole purpose of the PBM making more money.” At her center, the preference is to use certolizumab for women of child-bearing age with rheumatic disease. But one Kentucky insurance plan won’t allow use of the drug until a woman is pregnant or has failed to respond to every other treatment on every level of the formulary, she said.
To make the prior authorization process run more smoothly, she said, it’s important to stay up to date on insurers and their preferred agents. She also stressed being prepared with the detailed clinical information on why a particular agent is requested—the ideal, she said, is to put all of this information into every single visit note, with all of the medications a patient has tried and when. Also, avoid using paper submissions and stick with electronic submissions, she said.
When you get a denial, the options include changing regimens, doing a peer-to-peer review, submitting an appeal and using manufacturer bridge or patient assistance programs.
“All of them work,” she said. “We’ve used all of these in different scenarios with great success.”
State Legislature Roles in Pricing
Brian Henderson, director of state government affairs with Hart Health Strategies, a consulting and lobbying firm, outlined three issues affecting patients and physicians that are getting attention in state legislatures.
One is white bagging, in which health insurance companies and PBMs are requiring that physicians get medications through a specialty pharmacy rather than through traditional buy-and-bill means. Some states are banning this practice, and others have proposed legislation, Mr. Henderson said.
Another is prescription drug affordability boards. An appointed board reviews drug affordability and, if a drug is deemed unaffordable, sets an upper price limit. The problem, Mr. Henderson said, is that these limits don’t include the reasonable costs that go into administering these drugs. “They do not understand that you are also paid for the overhead that goes into administering the drugs that you furnish in your office,” he said. “You need to be weighing in with state legislators.”
