Impact of specialty pharmacy taking ownership of the prior authorization process of multiple sclerosis specialty medications to increase access todisease-modifying therapy

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 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 DMT. After several weeks of observation by an embedded clinical pharmacist in a large neurology practice, it was clear that many patients, were being delayed in starting their DMT due to lack of PA approval of DMT or through delay in the medical team having time to start the PA process. Additionally, many patients were receiving significant bills after their infusions were complete due to lack of PA prior to an infusible DMT. Previously, the PA may have been obtained after the patient received their DMT infusion, which may have resulted in significant payment for the patient.Objectives: The objectives were to increase the number of approved authorizations of DMT and increase the timeliness of authorizations in order for patients to receive appropriate and timely DMT as well as decrease the cost burden.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 7 March to 25 May 2018. 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 67 patients had a PA completed for their DMT (65 were infusible DMT). Fifty-seven (85%) of these PA’s were approved and of these, 11 patients qualified for free drug from the manufacturer. Ten PA’s were still pending approval on May 25th. Of the total PA’s completed originally, 11 were denied and thus appeal letters were completed. From the appeal letters, 7 (64%) PA’s were approved, 3 were pending results, and 1 patient decided to switch to an alternative DMT. Two of the appeals required 2 appeal letters be completed, and was approved after the second appeal letter.Conclusions: This program provides a new clinical service to increase the number of approved DMT to improve access and outcomes for MS patients.