Prior authorization balances dermatologic biologic use

September 1, 2007

THE ADVENT OF COSTLY biologic drugs for psoriasis hasn't inspired the inappropriate prescriptions many MCOs expected. But that's largely because MCOs are employing a firm hand in managing these drugs early on, educating providers and patients before new drugs come to market and implementing prior authorization (PA) requirements that balance patient access with cost effectiveness. While some policies occasionally require tweaking, sources agree that physicians are not taking these prescriptions lightly.

THE ADVENT OF COSTLY biologic drugs for psoriasis hasn't inspired the inappropriate prescriptions many MCOs expected. But that's largely because MCOs are employing a firm hand in managing these drugs early on, educating providers and patients before new drugs come to market and implementing prior authorization (PA) requirements that balance patient access with cost effectiveness. While some policies occasionally require tweaking, sources agree that physicians are not taking these prescriptions lightly.

"Biologics are pharmacy of the future," says Wendy Colin, PharmD, director of pharmacy for Preferred Care, a Rochester, N.Y.-based MCO. With the number of products entering the marketplace and research pipeline exploding, she says health plans must monitor new products versus currently available products and their relative cost efficiencies, considering dollars and patient outcomes.

Biologic drugs for psoriasis have clearly caught MCOs' attention. According to the recently published Galderma Quality Report for Dermatology & Managed Care, 90% of MCOs surveyed include biologic medications for dermatologic conditions on formulary, and 70% of respondents believe their use will continue growing. Additionally, the report says use of four-tier formularies to manage biologic drug costs grew more than 20% since 2004.

One plan taking this approach is Humana, says Derek Van Amerongen, MD, chief medical officer, Humana of Ohio. Humana covers all approved biologics, with PA, on tier four, which includes 25% coinsurance and a $2,500 annual ceiling on total out-of-pocket pharmacy costs. He says that while this might sound burdensome, Humana's policy allows patients to receive a full year of a chronic medication, regardless of total cost, for $2,500.

"Members need to know that [biologics] are extremely expensive drugs. They need to be involved with a meaningful part of the cost. At the same time, we don't want to create a barrier that will keep people who need these drugs from getting them," says Dr. Van Amerongen.

STAUNCH PA

To manage biologic psoriasis drugs, Preferred Care uses a robust prior authorization program, says Dr. Colin. Specifically, she says the company uses an open formulary but requires that a patient's condition fails traditional therapies prior to using biologics, provided there's no contraindication. The company's literature review shows traditional systemic treatments are "just as efficacious, if not more efficacious, than most biologics," all of which are associated with some level of complications, she says.

Additionally, with one biologic whose doses decrease after 12 weeks from twice weekly to once weekly, Preferred Care has had to spell out more clearly that it does not allow continuation at that high dose past 12 weeks. If a member flares while on therapy, the plan does not approve an increased dose during that flare because no literature shows this practice makes a significant difference.

Furthermore, Dr. Colin says that to continue therapy beyond three months, patients must achieve at least a 50% to 75% reduction in clinical symptoms including body surface area, or switch to another biologic.

EDUCATIONAL EFFORTS

For DakotaCare, a South Dakota State Medical Assn.-operated health plan serving more than 100,000 covered lives, psoriasis creates educational challenges, says Jacque Cole, RN, the organization's director, health plan compliance and clinical quality.

"Because we have so few dermatologists throughout the state, it's important to make sure that the general practitioners-plus nurse practitioners and physician assistants-understand what truly is a first-line medication," Cole says.