Impact of specialty pharmacy taking ownership of the prior authorization process of multiple sclerosis specialty medications to increase access to infusible disease-modifying therapy (DMT)

Abstract

Background: Multiple sclerosis (MS) is an autoimmune inflammatory demyelinating disease of the central nervous system (CNS) that is a leading cause of disability. Many disease-modifying therapies (DMT) with different routes of administration have been approved and introduced to the market to treat MS. These DMT are often costly and require Prior Authorizations (PA) which can lead to barriers in accessing DMT. This project was a response to the need for timely PA approval for patients needing infusible DMT. A previous project reviewed the impact of the specialty pharmacy taking ownership of all DMTs in regards to approved authorizations and timeliness of the approval. After this project highlighting the need and cost savings to the institution, an additional staff member was added to focus on infusible DMT PA. Aims: To increase the number of approved authorizations of infusible DMT and increase the timeliness of authorizations in order for patients to receive appropriate and timely DMT. Methods: The program was developed by a specialty pharmacy team and neurology team. The target audience were patients being initiated on a DMT for MS from September 2018–April 2019. A note was sent in the electronic medical record (EMR) to the pharmacy team to initiate the PA process when the neurologist prescribed a new DMT. Communication was made to the neurology team regarding the status of the DMT PA before scheduling a patient for their infusion. Results: A total of 92 patients had a new PA completed. Eighty-three (90%) authorizations were approved and three (3%) were denied. Of the three denials, additional appeals were done either by completing appeal letters or scheduling peer-to-peers. Two of the three patients then qualified to receive free medication through the manufacturer due to having two denials in place. One has applied for free medication and is currently pending. A total of 10 appeal letters were written, and seven peer-to-peers were set up for the attending physician. Five PAs were cancelled. Three of these required authorization through pharmacy benefits vs medical benefits, one received free medication through the manufacturer, thus the PA was cancelled, and one did not have a referral from the Veteran’s Association (VA) to be seen outside of the VA. One authorization was not covered due to the plan only covering preventative care. Overall, 89 (96.7%) patients received their DMT infusion. Conclusions: This program provides a new service to increase the number of approved infusible DMT to improve access and outcomes for MS patients.