Reducing the burden of prior authorizations

January 15, 2018

It’s a new year and a new round of headaches in obtaining prior authorizations for our patients’ medications. Let’s look at three issues practicing allergists face every day and especially at the start of each year.

First, formularies change frequently, and especially in January after insurance companies have made new deals with employers for coverage. I hope you like solving puzzles, because each insurance company likely has a new set of prior authorization rules – and it’s up to allergy practices to figure them out. This results in needing to, yet again, get prior authorizations for existing patients to continue their medications, or be shifted to different medications which are now covered because the ones they were previously on are no longer covered.  Is your head spinning yet?

Then there are biologics. These precision medicines can change the lives of our patients who suffer from urticaria, severe asthma and atopic dermatitis, but try to get insurance companies to understand that.

Getting asthma biologics covered initially is based on the patient’s lab values. To obtain reauthorization, or to change biologics affecting IL-5, coverage is based on the patient’s blood eosinophil count, which may be decreased since the patient has already been on a biologic that will lower it. Try getting the insurance company to understand why that happened. And for coverage for urticaria patients, some plans have mandatory six-month limits and then the patient has to come off to see what happens. Their disease worsens, and then we need another prior authorization to get them back on. Who is that benefiting?

And what about the time it takes to get these authorizations? In my practice, I have the equivalent of two and a half full time employees (FTE’s) working on prior authorizations. What kind of staff time does it take in your practice? We have to spend money to get our patients the care they need. Do you charge patients to obtain prior authorization? I don’t - at least not yet.

So, what can we do? The College hopes we have an answer to help ease your burden - the Prior Authorization Toolkit.

The toolkit’s 101 tab includes expert tips and tricks on how to make the process more efficient for your office and engaging patients in getting their medications covered.

Do you want the inside scoop on how insurance companies decide whether to approve your prior authorizations? The toolkit’s resources tab features a video from an allergist who is a medical director at a leading insurance company on how insurance companies evaluate prior authorizations and what they specifically want to see included.

Check out the resources to share with patients including links to videos from the Alliance for Patient Access and Consumer Reports articles with tips on how to reduce medication costs.

And when you get denials, the ground-breaking online prior authorization appeal letter generator helps you create customized appeal letters for specific medication/disease combinations in a few easy steps. The following are currently available with more to come this year:

  • Cinqair/Asthma
  • Nucala/Asthma
  • Xolair/Asthma
  • Xolair/Urticaria
  • Dupixent/Atopic Dermatitis

The toolkit is supported by Teva Respiratory.

Initial member feedback has been extremely positive. Let us know what you think. Are these tools helpful? Are there things that would make them better? Email us with your feedback.

Bradley E. Chipps, MD, FACAAI
ACAAI President