Drug Topics- August 11, 2008

35 Cover Story Pharmacists find PBMs have better prior authorization policies than insurers Pharmacy benefit managers have better policies on prior authorization than insurers do, according to pharmacists who responded to a recent Drug Topics survey on the subject. Web sites by Nov. 15. “We believe that making this information more transparent will facilitate the process for physicians, pharmacists, and patients,” Cynthia Tudor, director of the Medicare Drug Benefit Group, said. The information must be available for viewing, either from a link where the drug is displayed or from a general link on the formulary page. According to research by Georgetown University researchers, about 8% of all drugs included on Part D plan formularies last year were subject to a prior authorization requirement. “Transparency is always a step in the right direction,” Bruce Roberts, president of the National Community Pharmacists Association, said. “Whether it will save any time for pharmacists remains to be seen.” The new CMS transparency mandate will not necessarily encourage plans to make fewer drugs part of the prior authorization process, Jack Hoadley, Ph.D., a professor at Georgetown University’s Health Policy Institute, said. “The issue for patients, and therefore healthcare providers, is whether prior authorization transparency will make the [Part D] plans more competitive,” he said. “It might, but if it does, that will take some time.” In the meantime, “community pharmacists will continue to address the issue of prior authorization and the burden it puts on their practice professionally and efficiently,” Roberts said. Plan or PBM Excellent Average Poor or or good very poor Do not know Medco Express Scripts Caremark Aetna Cigna Humana WellPoint 20% 19 18 14 11 12 11 35% 38 38 37 39 39 37 30% 29 29 25 26 31 29 14% 15 15 24 24 18 23 Part D plans must soon publish prior authorization criteria In a move that the Centers for Medicare & Medicaid Services hopes will speed the prior authorization process, Part D plans must post their approved prior authorization criteria on their when we know the customer’s history well and when the patient has been on the same medication for years, would improve the system,” one respondent said. “But it is still very complicated.” One respondent had a particularly innovative idea: “Pharmacists would be able to drastically reduce the amount of time spent on prior authorization if drug plans and insurance companies, especially Medicare Part D, would agree to cover the initial prescriptions for maintenance drugs while making it known to the pharmacist and patient that a prior authorization is required before the prescription is refilled,” the respondent said. “The majority of maintenance drugs are filled for a 30-day supply. This would allow the pharmacist and physician more than enough time to obtain a prior authorization before the drug is due for a refill.” Many pharmacists recommended that PBMs and health plans handle prior authorization by drug class. “Cut out prior authorizations for drugs that have had generic equivalents available for at least a year,” a pharmacist said. “Prior authorization for generic or inexpensive drugs makes no sense.” Although they have questions and doubt about the rationale for prior authorization decisions, the core of the problem for most pharmacists is lack of adequate information. They view the process as purposeful obfuscation on the part of payers. “PBMs should be required to give better explanations as to why a drug is rejected for a prior authorization,” one respondent said. “They should be required in their rejection to list covered drugs and categories, give explanations as to why a drug prior authorization is now rejecting, and let us know the pertinent information to get it [approved, including] the correct phone numbers and what information the doctor needs to submit.” “The point is that it can be improved,” one optimistic respondent said. “Anything can be.” THE AUTHOR is a writer based in Gettysburg, Pa.

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Drug Topics- August 11, 2008 Contents Latebreakers Letters DEA Proposes Rule To Allow Electronic Prescriptions for Controlled Substances Merger, Medicare Reform Could Mean Broader E-Prescribing Adoption New Combination Pill Approved for Type 2 Diabetes New Eczema Guildlines Promote Use of Emollients, Then Topical Corticosteroids Agencies Flush Original Strategies in Favor of Promoting Drug Take-Back Programs JP at Large: You Laughing at Me? Pharmacists Find Themselves at Mercy of Prior Authorization State Law Requiring PBM Transparency See Some Gains, Some Losses Global Counterfeiting Still Growing, Says U.S. Commerce Official FDA Saftey Page: Prophylthiouracil Still Confused with Purinethol (mercaptopurine) New Products Bring Lice Treatment to a Head NACDS Marketplace Showcases New Product that Fill Unmet Needs Update on Respiratory Tract Infections Execs Share War Stories About Adopting Technology in their Stores New Products Advertisters Index Classified Viewpoint: Medicare Part D Revisions sorely needed

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