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Utilization Management in Women’s Health


A medical professional explains the many facets of the prior authorizations process for drugs in women’s health.

Ryan Haumschild, PharmD, MBA, MS: Prior authorizations are something that we’re used to on the payer side. Our health care providers don’t always get excited about them, but what they do is allow us to manage these medications effectively. What I mean by that is we can always match the medication to an indication. We want to make sure that these medications are being prescribed appropriately, that they’re indicated for the specific patient, and at the end of the day, that we’re being good stewards of these medications. We want to make sure that we know specifically what indication [is for] the medication. Is it being prescribed on label or off label? Prior authorizations allow for better utilization management of those therapies.

Prior authorizations are triggered by high cost or high touch medications. That means medications that could cause safety concerns, a higher cost of care, or just expensive medication. That would trigger a prior authorization review. It can still be timely, but it allows us to also be familiar with what the latest medication being requested is and if there is something we’re not considering as part of the early access pathway that we should. Prior authorization is a tool we use on the payer side to match things up and create trends per indication of how specific medications are being prescribed.

If I talk to my provider colleagues, there are going to be mixed preferences. I feel they serve a unique need because they allow us to make sure people are prescribing these agents for their indication and prescribing appropriately. There are so many different prescribers out there who are prescribing for contraceptives, or GnRH [gonadotropin-releasing hormone] antagonists, that prior authorizations allow for equal oversight and to make sure there’s proper utilization. I think they’re being utilized, but in this case, they’re most likely approved as long as someone’s not using it inappropriately.

There’s a high percentage of drugs that are getting prior authorization for endometriosis, especially because there are newer oral analogue agents that are being prescribed. More than 70% of these agents are going through a prior authorization, either through retail or specialty claims. That is making sure we’re having proper utilization of these newer agents. As we look at injectable vs oral, there’s appropriate management. Also, with endometriosis, you want to make sure that patients who have any type of pain or discomfort are getting the right agent that will provide the best efficacy. Those are some of the reasons why you’re still seeing a high percentage of prior authorizations, specifically for endometriosis, and sometimes for uterine fibroids.

There’s a high approval process. That’s because the Affordable Care Act came out with their declaration to provide better access to these medications. If there’s not a big contraindication, or if something’s not being used off label, we’re most likely approving it, if most of the indications and the therapies check out.

The administrative burden is higher than normal. The administrative burden on the providers and the clinic can sometimes be frustrating, but on the payer side, there’s an administrative burden that we’re always trying to manage. The silver lining to this is that we’re very in touch with what patients are being prescribed. We have good oversight of the utilization management, and we can make sure these newer medications are being prescribed on label. Lastly, a lot of therapy deals with sequencing as well, so we want to make sure people are trying different therapies for their patients in the right sequence. [That way,] if something doesn’t work, there are additional therapies they can still gain access to.

There are occasions when prior authorizations are not approved, and I think it has to do with off-label use. If someone’s prescribing an agent off label, it may not always get approved, or if it is going to get approved, we may ask for an appeal with medical necessity or justification. That’s another common reason. Another reason we might not see prior authorizations approved is due to the lack of information that’s being submitted. In other words, if someone does not fill out the prior authorization completely and leaves out important medical information that we want to review, that may lead to a denial. That doesn’t mean someone can’t appeal it, but that would lead to an initial denial to ensure that people are utilizing these agents appropriately.

I love my OB-GYNs [obstetrician-gynecologists], and they’re always trying to do the right thing for the patient. I think they see prior authorizations as burdensome, and sometimes they do not see the same value that we might see in prior authorizations. As we move forward, the more we can align treatment pathways [and have] a clear understanding of how we would sequence agents, you might see a reduction in prior authorizations. There are other disciplines where they’re used to prior authorizations. It’s part of the normal course of treatment, but for OB-GYNs, their lack of use and exposure to them might be a barrier. In the end, we want to work through [frustrations] so we can assure appropriate use.

This transcript has been edited for clarity.

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