Abstract
Background: The proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors significantly reduce the risk of major adverse cardiovascular events in high risk patients. The most significant barrier with these drugs is cost (estimated average wholesale price [AWP] $14K per year). For these drugs to be cost-effective, their cost needs to be ∼1/3 of their current AWP. The use of these drugs requires payer approval with substantial provider and clinic staff resources needed to gain prior authorization (PA).
Objectives: To justify the utilization of a disease-state pharmacy medication expert in the cardiology clinic to assist with benefit investigation and prior authorization efforts for this class of medication to optimize prescription approval rates.
Methods: A pharmacy technician from the integrated delivery network (IDN) who received training in the role of medication access coordinator (MAC) was placed in the outpatient cardiology clinic late in 2017. The MAC worked with clinic providers, specialty pharmacy, payers, and pharmaceutical company representatives to streamline the traditional methods of benefit investigation and the PA process.
Results: From December 2017 to April 2018, the MAC reviewed and assisted with PCSK9 inhibitor PA in 325 cardiac patients. Of the 325 patients, 48 were pending PA, currently denied, or pending medication trial. PA approval in the remaining patients were: 8 with Medicaid ($0 copay); 88 with commercial insurance (≤$10 monthly copay); 80 with Medicare and Amgen Safety Net foundation ($0 copay); 15 pending for the Medicare/pharmaceutical manufacturer foundation; 8 with low income subsidy (LIS) (≤$8.35/90 day copay); 6 with Medicare and alirocumab (Praluent®) Assistance (PASS $0 copay) with 4 others pending approval; and 1 with the Pan Foundation. The remaining 67 had Medicare coverage and an adjusted gross income >$83,000/year. These patients opted not to receive treatment due to cost. As an indicator of the success of the MAC initiative, the success rate of evolocumab (Repatha®) approvals for the IDN across the country is 82%. This is compared to 62% regionally and 60% nationally for non-IDN patients. This shows the impact of the implementation and approval success of the MAC role.
Conclusions: There is clear benefit of the MAC in the cardiology clinics of the IDN. PA rates with these drugs are among the most challenging of all specialty drugs. By channeling benefit investigation and PA through the MAC, PA approval was increased by 20%. Similar approaches using a MAC in other disease states should improve specialty pharmacy medication approvals.