A Comparison of Coverage Restrictions for Biopharmaceuticals and Medical Procedures

Chambers, James D.; Pope, Elle; Bungay, Kathy; Cohen, Joshua T.; Ciarametaro, Michael; Dubois, Robert W.; Neumann, Peter J.

doi:10.1016/j.jval.2017.10.007

Cited by 4 publications

(5 citation statements)

References 7 publications

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“…Payer compendia may vary access to medications independent of value based on inconsistent and inefficient coverage standards. 15 An example includes different medication access requirements for medical billing vs prescription benefit billing. 15 In this report, one case did not overcome the prescription benefit requirements even with an appeal.…”

Section: Discussionmentioning

confidence: 99%

“…15 An example includes different medication access requirements for medical billing vs prescription benefit billing. 15 In this report, one case did not overcome the prescription benefit requirements even with an appeal.…”

Section: Discussionmentioning

confidence: 99%

“…This approach highlights potential coverage discrepancies. 15 PA denials occur even for medications used in accordance with guideline recommendations or high quality evidence. A same maintenance and reliever therapy (SMART) strategy has been recommended by the Global Initiative for Asthma as the preferred maintenance and reliever therapy since 2019.…”

Section: Discussionmentioning

confidence: 99%

“…Instead, this case gained access through an infusion suite with medical billing. This approach highlights potential coverage discrepancies 15 …”

Section: Discussionmentioning

confidence: 99%

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Leveraging ambulatory care pharmacist expertise in medication appeals to overcome access barriers: A descriptive report

Hvisdas

Goode

Lee

et al. 2022

J Am Coll Clin Pharm

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Introduction Prescription prior authorization (PA) and prohibitive out‐of‐pocket costs are encountered across all specialties of care. These barriers are burdensome for prescribers and patients due to the multiple steps required to gain approval for payer reimbursement for medications. Objectives The primary objective was to characterize clinical pharmacist impact on medication appeals and high cost resolution. Methods This was a retrospective review of medication access intervention data collected from January 1, 2021, through July 31, 2021, at an academic medical center where five clinical pharmacists are embedded across 11 specialty and family medicine clinics. Intervention data was documented for both specialty and nonspecialty prescriptions. The primary end point quantified and characterized interventions based on access issues, defined as insurance denial or high out‐of‐pocket cost. Additional end points included time to appeal determination, total time spent on appeal activities, the incidence of denials, duration of the interruption, and assistance dollars secured for cost‐related barriers. Results Over the 7‐mo period, there were 531 prescriptions identified for clinical pharmacist access intervention. Of the total interventions collected, 42% (n = 221) were appeals for insurance denials and 58% (n = 310) addressed high out‐of‐pocket cost. The approval rate of appeals was 94% (n = 208). The majority of appeals (89%) were submitted within 3 d. The median time to appeal determination was five calendar days. The estimated time spent on appeal activities by the clinical pharmacists was 6.8 work wk. There were 51 patients of therapy interruption. The total assistance dollars secured for high out‐of‐pocket costs reached an estimated $1 953 200 over the report period.ConclusionThis report characterizes an approach to effectively manage medication appeals and cost resolution through embedded clinical pharmacists. Leveraging embedded pharmacists' clinical knowledge and familiarity with payer processes in medication appeals achieved a 94% approval rate. The current payer process places a burden disproportionately on prescribers and patients, delaying or preventing medication access.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

“…Instead, this case gained access through an infusion suite with medical billing. This approach highlights potential coverage discrepancies 15 …”

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

Leveraging ambulatory care pharmacist expertise in medication appeals to overcome access barriers: A descriptive report

Hvisdas

Goode

Lee

et al. 2022

J Am Coll Clin Pharm

View full text Add to dashboard Cite

show abstract

“…Heretofore, much has been made about value, but implementation has been more challenging [2][3][4]. In the analysis conducted by Chambers et al [5], the authors compare the degree of restrictiveness of coverage for select medical and pharmacy benefits across a sample of large US health insurers. A unique aspect of this analysis was that the cost effectiveness of the interventions was incorporated into the analysis using cost-effectiveness thresholds ranging from $50,000 to $150,000 per quality-adjusted life-year.…”

mentioning

confidence: 99%

Are US Health Insurers Efficient or Not?

Malone

2018

Value in Health

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Social Factors of Health Care: a Thematic Analysis of First and Second Year Medical Student Reflections

et al. 2021

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A Comparison of Coverage Restrictions for Biopharmaceuticals and Medical Procedures

Abstract: Therapy access depends on factors other than cost and clinical benefit, suggesting potential health care system inefficiency.

Cited by 4 publications

References 7 publications

Leveraging ambulatory care pharmacist expertise in medication appeals to overcome access barriers: A descriptive report

Leveraging ambulatory care pharmacist expertise in medication appeals to overcome access barriers: A descriptive report

Are US Health Insurers Efficient or Not?

Social Factors of Health Care: a Thematic Analysis of First and Second Year Medical Student Reflections

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