Background/Purpose: As the use of specialty pharmacy drugs has grown, many insurers have instituted strict prior authorization requirements, ostensibly to ensure that the right patients get the right medications at the right point in their disease process. Rheumatologists, dermatologists, and patients, however, often question whether this process creates logistical barriers that delay treatment. Northwestern Medicine established a specialty pharmacy in 2014 to provide medication directly to patients at the institution. Rheumatology and dermatology clinics began working with this specialty pharmacy in 2015 and now utilize it for all new specialty drug prescriptions. When possible, medications are filled directly through the health system pharmacy. When insurers require use of an alternative specialty pharmacy, the prescription is transferred, but the NM specialty pharmacist continues to help guide the prior authorization steps. We analyzed the number of prescriptions approved or denied through this process, hypothesizing that few medications requiring prior authorization were ultimately denied.

Methods: We reviewed prior authorization requests from 6/1/2015 through 6/12/2017. We included primarily prescriptions for approved indications, at labeled doses. Indications included ankylosing spondylitis, juvenile idiopathic arthritis, psoriatic arthritis, rheumatoid arthritis, and psoriasis.

Results: Of the 3192 prescriptions handled by the specialty pharmacy, 840 did not require prior authorization. A total of 2,352 prior authorizations were submitted; 2113 of these were approved with the initial request, and 239 (10.1%) were denied. Appeals were submitted for 126 of these denials in rheumatology; the denial was overturned in 83 cases, upheld in 40, and 3 are pending. Dermatologists appealed fewer denials. As of the data cut, 2196 (93.4%) of the prescriptions submitted for prior authorization had been approved and filled. Results for individual diseases are shown in Table 1.

Conclusion: In our academic medical practice, rheumatology and dermatology specialty medications prescribed for approved indications are seldom denied, and most of the denials are reversed when appealed. These findings suggest that the time spent on prior authorizations, at substantial cost to the practices involved, may be unnecessary, as appropriate treatments are rarely denied. Insurers may have other interests in the prior authorization process besides the stated reason of restricting inappropriate or unnecessary prescriptions. There appears to be little value in the prior authorization process for rheumatology- or dermatology-specific specialty drugs prescribed in an academic practice. A more streamlined approach could limit wasted time and effort, suggesting a need for exploration of alternative methods in partnership with payers.

Table 1. Prior Authorization Status for Specialty Drugs in Rheumatology and Dermatology