COMMENTARY

Tips for Navigating Prior Authorization and Out-of-Pocket Costs for HFrEF Medications

Larry A. Allen, MD, MHS; Sarah J. Sarni, BSN, BA

Disclosures

May 11, 2021

Editorial Collaboration

Medscape &

Tools to Facilitate the Prior Authorization Process

Off-patent medications with multiple generic options often cost $4 per month or less. Conversely, "cash" or "list" pricing for drugs still on-patent, including sacubitril-valsartan, SGLT2 inhibitors, ivabradine, and vericiguat, each generally cost in excess of $500 per month. Therefore, the average patient requires some form of financial assistance (usually through health insurance) to reasonably access these drugs. However, to ensure necessary and appropriate use of the medication — thereby controlling cost as well — many insurers have prior authorization requirements in place that must be completed after a prescription is written but before payment is approved. Even after patients receive authorization for the drug, they are often responsible for a significant copayment. This results in a complex, time-consuming, and frustrating process for patients, physicians and advance practice providers, nurses, pharmacists, and administrators, which often has detrimental effects on treatment and the patient experience.

As an example, insurance coverage for sacubitril-valsartan has been gradually increasing since its approval; however, plans often require prior authorization, which generally requires documentation of recent left ventricular ejection fraction ≤ 40% and New York Heart Association functional class II-IV. With expanding evidence and cost-effectiveness analyses showing good value, as of 2018 100% of Medicare Part D plans covered sacubitril-valsartan, with the minority requiring prior authorization (1069 of 2818 plans [38%]). Most prior authorization processes are triggered at the time a prescription is passed by the pharmacy to the insurer; the insurer in turn reaches back to the prescribing healthcare provider, who must justify the medication for the patient.

To advocate for principled reform and help physicians navigate the prior authorization process, the American College of Cardiology (ACC) developed a Prior Authorization Reform Hub. This site includes reporting tools for proprotein convertase subtilisin-kexin type 9 inhibitors and cardiac procedures to collect data on disputed requests and coverage denials. In addition to the ACC hub, the American Medical Association, as part of its prior authorization reform initiatives with other medical and healthcare organizations, offers practice resources, including videos, and guides to help clinicians work through the prior authorization process.

In an attempt to help streamline the prior authorization process, many insurers also now point clinicians to third-party software solutions, such as CoverMyMeds and Surescripts, that provide HIPAA-compliant, standardized mechanisms to review, complete, and track prior authorization requests for all insurance plans and medications.

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