ACR Meeting Abstracts

ACR Meeting Abstracts

  • Home
  • Meetings Archive
    • ACR Convergence 2022
    • ACR Convergence 2021
    • ACR Convergence 2020
    • 2020 ACR/ARP PRSYM
    • 2019 ACR/ARP Annual Meeting
    • 2018 ACR/ARHP Annual Meeting
    • 2017-2009 Meetings
    • Download Abstracts
  • Keyword Index
  • Advanced Search
  • Your Favorites
    • Favorites
    • Login
    • View and print all favorites
    • Clear all your favorites
  • Meeting Resource Center

Abstract Number: 205

What Is the Value of the Prior Authorization Process in Specialty Drug Therapy?

Shally Alendry1, Melad Qodsi1, Travis Hunerdossse1 and Eric M. Ruderman2,3, 1Northwestern Medicine, Chicago, IL, 2Northwestern University Feinberg School of Medicine, Chicago, IL, 3Medicine/Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, IL

Meeting: 2017 ACR/ARHP Annual Meeting

Date of first publication: September 18, 2017

Keywords: Insurance and prescribing trends

  • Tweet
  • Email
  • Print
Session Information

Date: Sunday, November 5, 2017

Session Title: Health Services Research Poster I

Session Type: ACR Poster Session A

Session Time: 9:00AM-11:00AM

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

Disease

Approved

Denied

Not Needed

Appeal Granted

Appeal Denied

Appeal

Pending

Ankylosing Spondylitis

133

11

45

2

2

–

Juvenile Idiopathic Arthritis

17

2

4

2

–

–

Psoriasis

648

103

288

8

7

1

Psoriatic Arthritis

253

31

78

20

7

1

Rheumatoid Arthritis

1062

92

425

51

24

1

Total

2113

239

840

83

40

3

 


Disclosure: S. Alendry, None; M. Qodsi, None; T. Hunerdossse, None; E. M. Ruderman, Pfizer Inc, 5,Roche Pharmaceuticals, 5,Seattle Genetics, 5,Abbott Immunology Pharmaceuticals, 5,Amgen, 5,Pfizer Inc, 2,Bristol-Myers Squibb, 5,Janssen Pharmaceutica Product, L.P., 5,Eli Lilly and Company, 5,Novartis Pharmaceutical Corporation, 5.

To cite this abstract in AMA style:

Alendry S, Qodsi M, Hunerdossse T, Ruderman EM. What Is the Value of the Prior Authorization Process in Specialty Drug Therapy? [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). https://acrabstracts.org/abstract/what-is-the-value-of-the-prior-authorization-process-in-specialty-drug-therapy/. Accessed February 4, 2023.
  • Tweet
  • Email
  • Print

« Back to 2017 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/what-is-the-value-of-the-prior-authorization-process-in-specialty-drug-therapy/

Advanced Search

Your Favorites

You can save and print a list of your favorite abstracts during your browser session by clicking the “Favorite” button at the bottom of any abstract. View your favorites »

ACR Pediatric Rheumatology Symposium 2020

© COPYRIGHT 2023 AMERICAN COLLEGE OF RHEUMATOLOGY

Wiley

  • Home
  • Meetings Archive
  • Advanced Search
  • Meeting Resource Center
  • Online Journal
  • Privacy Policy
  • Permissions Policies
  • Cookie Preferences