Understanding Prescription Pathways for Biologic Medication Therapy

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Executing evidence-based medicine in the U.S. is challenging, especially utilizing high-cost medications in rheumatologic care. As patients trust their clinicians to be their medical experts, clinicians must trust their care team members to be experts at implementing the care plan. A clinician’s knowledge of human anatomy and physiology is the foundation to understanding pathophysiology. From this knowledge base, clinicians can diagnose and choose treatments or solutions.

This concept can be applied to navigating the complex journey of a self-administered biologic or high-cost small-molecule prescription. Having an understanding of the third-party establishments involved allows us to understand when a pathogenesis has occurred in a prescription pathway and, in turn, know how to react or adapt solutions to ensure treatment success.

This topic will be discussed during a concurrent session at the 2016 ACR/ARHP Annual Meeting on Monday, Nov. 14, 2016, from 7:30–8:30 a.m.: Biologic Therapy: Prescription, Prior Authorization and Beyond. Below, you’ll find some of what will be presented:

Understand the Landscape

The major industries influencing the prescription pathway are pharmacy benefit management companies, pharmaceutical companies and specialty pharmacies. Competitions in the industries create variations in prescription pathways. The intent of each organization may be decent, but the complexity of multiple self-serving initiatives continually creates new barriers to the execution of the care plan from the patient’s and provider’s viewpoints. Patients and clinicians may perceive these complexities as complete roadblocks outside of their control.

Although legislation may be necessary to regulate third-party industries affecting patient care, waiting around for this to happen is not in the best interest of our patients. There is a major need to educate our care team members on these third-party industries so we can identify the barriers and implement proactive practice solutions to increase the probability of treatment success.

Rheumatology team members who understand the third-party landscape will be best prepared to execute care plans utilizing self-administered biologic and small-molecule therapies. Transparent education of the industries dictating access and distribution policies will increase awareness and understanding, and provide a foundation for proactive practice solutions.

The Players

A pharmacy benefit management company is a third-party administrator of prescription drug programs for commercial health plans, self-insured employer plans, Medicare Part D plans, the Federal Employees Health Benefits Program and state government employee plans. The most common pharmacy benefit management companies you will encounter are Express Scripts, CVS Health (formerly CVS Caremark) and United Health/OptumRx/Catamaran; these companies have an approximate 80% share of the market.¹

Practices routinely encounter communications from pharmacy benefit managers in the form of medication prior authorizations and appeals. It’s important to understand that prior authorizations and appeals may or may not be directly managed by the pharmacy benefit manager. This is a common area of confusion. Finding out which organization and, specifically which department within the organization, is responsible for processing the communications will improve the success of treatment coverage.

In addition to being a third-party administrator of prescription drugs, a majority of pharmacy benefit managers own and operate specialty pharmacies.

Specialty pharmacies are all competing for access to patient lives in need of high-cost therapies to be dispensed. It is important to understand what avenue a specialty pharmacy takes to gain access to patient lives.

Some specialty pharmacies align with pharmacy benefit managers and insurers to enforce pharmacies align with pharmaceutical companies to provide data and expertise for specific therapies. Specialty pharmacies also align with providers to assist in navigating the complexities brought on by third parties and to utilize the pharmacist in direct and indirect care. They are also partnering with all three—pharmacy benefit management companies, pharmaceutical companies and providers.

Pharmaceutical companies contract with third-party hub service companies to administer patient access, reimbursement and maintenance therapy programs for their proprietary products. Common services provided are co-pay assistance, benefits investigation, free drug programs and patient support. Hub service com­panies can be standalone businesses or internal business units of pharmacy benefit man­agers, specialty pharmacies and internal components of the pharmaceutical companies.

Understanding the relationships and reputations of these third-party com­panies in your community will help practices implement strategic policies that improve your patient’s prescription journey, medication adherence and clinical outcomes.

Limited Distribution

Another factor affecting the prescription pathway is medications with limited distribution policies. Limited distribution is a strategy used by pharmaceutical companies to have more control of the supply chain. Typically, a limited distribution medication will be exclusively dispensed by one or a select number of specialty pharmacies chosen by the pharmaceutical company.

Knowledge Is Power

Understanding that there are several industries influencing the prescription pathway will help care team members navigate the complexities of the patient’s journey once a self-administered biologic or small-molecule medication is prescribed. Pharmacy benefit management companies, pharmaceutical companies and specialty pharmacies often overlap and serve multiple purposes. Find the best way to unravel the complexities for your patients.

Andrew Hochradel, PharmD, is the director of specialty pharmacy for Prescriptions Plus in West Allis, Wis.

Reference

1. Balto DA. The state of competition in the pharmacy benefits manager and pharmacy marketplaces. House Judiciary Subcommittee on Regulatory Reform, Commercial, and Antitrust Law. 2015 Nov 17. https://judiciary.house.gov/wp-content/uploads/2015/11/114-52-97631.pdf.