Pre-authorization is commonplace for all kinds of medical treatments to ensure patients are receiving the right treatments at the right time. But when it comes to specialty drug preauthorization, there is a unique potential for conflicts of interest, as a recent article in the MyHealthGuide Newsletter written by L.G. Hanzel of RxResults explains.
It turns out that a lot of pharmacy benefit managers (PBMs) own specialty pharmacies. That means the same company that will be dispensing a plan’s specialty drugs is responsible for managing the preauthorization process for those drugs, raising concerns about the objectivity of the preauthorization process. This potential conflict of interest may put plan sponsors at risk, with some Fortune 100 companies facing lawsuits regarding their fiduciary.
There is another option, Hanzel suggests. One way to maintain an objective preauthorization process for specialty drugs is to engage a third-party entity. Carving out prior authorization from services provided by plan PBMs and relying on an independent party is a simple step sponsors can take to protect themselves, manage costs, and ensure impartiality.
Why Use a Third-Party for Specialty Drug Prior Authorization?
A carved-out prior authorization review of specialty drugs removes conflicts of interest and provides:
- Proactive patient protection from unnecessary specialty drugs that are often powerful, potent medications with potentially harsh side effects
- Mitigated risk and fiduciary responsibility in managing the plan assets
- Financial savings/discounts from stop-loss carriers who also encourage an independent prior authorization review of specialty drugs
- Potential savings for both the health benefit plan and the participant
What to Consider When Selecting a Prior Authorization Service Provider
According to Hanzel, these factors are essential for plan sponsors to consider when selecting a specialty-drug prior authorization service provider:
- Patient safety
- Urgency, time sensitivity, and efficiency of the review process
- Evidence-based clinical criteria and expertise
- Data-driven financial and utilization metrics
- Active pharmacy and therapeutics committee to review the drug pipeline and current peer-reviewed research
- Independently developed clinical prior authorization criteria without PBM or drug manufacturer influence
- Access to collaborative medical expertise, literature, and clinical research
- Understanding of plan sponsors’ responsibility for patient safety and financial prudence
- Proven track record of successfully integrating independent prior authorization services with PBMs
So how do plan sponsors identify a third party for specialty drug preauthorization that does not pose a conflict of interest? Hanzel has advice for navigating the selection process, too.
Look for a third-party entity that meets these criteria:
- No financial ties to pharmaceutical manufacturers
- No financial ties to pharmacy benefit managers
- No financial ties to pharmacies filling prescriptions—specialty, retail, or mail order
- All pharmaceutical and therapeutics committee members have no financial ties to pharma
- The service provider’s only source of revenue is a transparent administrative fee
With the right third-party preauthorization review process, sponsors can avoid potential conflicts of interest and ensure the best outcomes for patients.