Abstract: Evaluation and Comparison of Prior Authorization Policies for Specialty Drugs
Background: In healthcare management, Prior Authorization (PA) policies are pivotal, particularly for specialty medications, offering benefits like cost control and preventing inappropriate use. However, the variations in these policies necessitate understanding and optimization to ensure optimal patient care and cost control.
Study Objective: This study aims to provide insights for employers, who bear the financial responsibility for PA policies, by comparing PA policies of specialty drugs among traditional and transparent Pharmacy Benefit Managers (PBMs).
Methods: A comprehensive analysis was conducted on 338 specialty medications, scrutinizing publicly published PA policies from six PBMs, comprising four traditional PBMs and two transparent PBMs. Parameters including authorization duration, diagnosis requirement, specialist necessity, laboratory measurements, genetic testing, prior therapy failure, medication exclusion, and age limits were examined to assess their impact on cost and patient care.
Results: Significant variation was found across PBMs in PA policy requirements. Traditional PBMs exhibited lower average requirements per policy compared to transparent PBMs. PA policies of transparent PBMs more closely resembled clinical trial evidence for each drug compared with traditional PBMs, which, at times, omitted clinically relevant requirements. Out of the 338 medications analyzed, a majority required prior authorization. One transparent PBM had PA policies for only 41% of medications, whereas other PBMs had policies for over 80% of medications. Authorization duration varied widely, with ESI granting the longest average duration of 18.4 months and Ventegra the shortest of 8.1 months. Transparent PBMs also had the highest average number of requirements per policy, with the highest being 5.3, while CVS Caremark had the lowest at 2.7.
Discussion: The study underscores the substantial impact of PA policies on both employer costs and patient care. While transparent PBMs often impose more stringent requirements, aligning closely with clinical evidence and optimizing patient outcomes, the wide variation across PBMs raises significant concerns about cost control and administrative burden. Of particular note is the observation that traditional PBMs tend to implement policies with fewer requirements, even when additional clinical indicators are warranted. While this approach may seemingly reduce administrative burdens and streamline patient access, it also carries substantial risks. Omitting clinically relevant requirements jeopardizes patient safety and may lead to suboptimal treatment outcomes. For employers, this presents a pressing concern, as they may unknowingly be funding PA policies that fail to adequately safeguard patient health while potentially inflating medication costs.
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This underscores the necessity for employers to conduct thorough audits of their PBMs' PA policies. By scrutinizing these policies for adherence to clinical best practices and evidence-based criteria, employers can ensure that their resources are being optimally utilized to support employee health and well-being. Furthermore, such audits serve as a proactive measure to safeguard against unnecessary financial expenditures on medications that may not offer the best value in terms of patient outcomes. In essence, by taking a proactive stance in auditing PA policies, employers not only demonstrate their commitment to employee health and safety but also position themselves to make informed decisions that optimize healthcare benefits and financial resources.
Conclusion: For employers, understanding the nuances of PA policies is crucial in managing healthcare costs effectively while ensuring quality care for employees. Standardization and transparency in PA policies are essential to mitigate administrative burdens and ensure safe, cost-effective care. Future research should focus on the long-term financial implications and health outcomes associated with different PA policies, aiding employers in making informed decisions to optimize healthcare benefits for their workforce.