Background/Purpose: Insurance companies have inconsistent formularies that do not align with Rheumatology clinical treatment guidelines. We are faced with the ongoing challenge of insurance companies denying access to specialty medications for patients with very individualized needs. This abstract will examine the common reasons for insurance denials of specialty medications and how pharmacist intervention can impact these denials.

Methods: A retrospective analysis of pharmacist interventions pertaining to insurance denials of prescribed specialty medications was conducted. The interventions consisted of pharmacist written appeal letters for 41 denials (98%) and providing supporting literature for 1 denial (2%). Another data point considered was the number of medication claims for off-label use versus FDA-approved use. The data was compiled from pharmacy intervention records which occurred from July 2019 through May 2020.

The denials involved the following specialty medications for reference: abatacept, adalimumab, anakinra, apremilast, canakinumab, certolizumab, etanercept, infliximab, ixekizumab, pirfenidone, rituximab, secukinumab, sildenafil, tadalafil, tocilizumab, and tofacitinib.

The denials involved the following diagnoses for reference: Adult-Onset Still’s Disease, AS, Autoimmune Inner Ear Disease, Behcet’s Disease, Checkpoint Inhibitor-induced Arthritis, Chronic Recurrent Multifocal Osteomyelitis, Familial Mediterranean Fever, IgG4-Related Disease, Myhre Syndrome, Psoriatic Arthritis, Raynaud Phenomenon, Recurrent Pericarditis, Relapsing Polychondritis, Rheumatoid Arthritis, SAPHO Syndrome, Schnitzler’s Syndrome, and SLE.

Results: Of the 42 insurance denials that required pharmacist intervention, 32 (76%) were medication claims for off-label use and 10 (24%) were for FDA-approved use.

Of the 42 challenged insurance denials, 30 denials were overturned (71%) and 12 denials were upheld (29%). Of the 30 overturned denials, 24 (80%) of the approvals were for medication claims for off-label use and 6 (20%) were for FDA-approved use.

Of all appeal approvals, the average time from date of denial to date of approval was 9 days.

The reasons for initial insurance denials were as follows: non-FDA approved use (27; 64%), step therapy requirements (12; 29%), and quantity limits (3; 7%).

Conclusion: Rheumatologic conditions are progressive and debilitating. In consequence, it is necessary to tailor treatments to the individual patient and not allow medication access to be at the discretion of the insurance company. Based on the data presented, a significant percentage of insurance denials were due to non-FDA approved use or step therapy requirements. Greater than two-thirds of the analyzed insurance denials were overturned, with a remarkable average turnaround time of 9 days. Pharmacists have advanced clinical training and skills to conduct literature review, making them very effective in overturning insurance medication denials, and increasing patient access to medications as a result. It is indicated that pharmacists are a valuable asset to increase the focus on unchallenged insurance denials and reduce existing burden on providers to improve patient care in a timely manner.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/pharmacist-intervention-reducing-insurance-denials-of-specialty-medications/