Electronic Prior Authorization and First Fill Co-pay Programs Support Patient Access and Adherence

As published by PharmaLive magazine | Read the full article

By David Fidler, Senior Director Product Innovation at ConnectiveRx

For both patients and their healthcare providers (HCPs), the requirement that prior authorizations (PAs) be obtained from health insurers for many branded and specialty medications continues to act as a significant roadblock. Recent AMA survey data show not only that it continues to interfere with patient care and can lead to adverse consequences, but that HCPs and their staff spend an average of two full business days (16 hours) per week completing PAs.[1] 85% of HCPs describe the burden associated with PA as high or extremely high.[2]

An approval delay of even a few hours hinders access to treatment and increases the risk of abandonment. Despite calls to reform our current PA system in order to reduce administrative burdens on HCPs and their staff and reduce patient waiting time, there is little indication that changes will happen any time soon.[3]

So how can pharma brands help overcome this roadblock in order to better support patient adherence and keep their first-choice status with HCPs?

The Benefits of Using Electronic Prior Authorizations in Combination with Co-pay Programs

While responses to traditional PAs can take days or weeks, electronic PAs (ePAs) can be determined in just a few minutes when the required information is submitted quickly and the decision is straightforward. The increasingly widespread use of ePAs is significantly improving adherence.

More often than not, though, the approval process for prior authorizations is not simple. When approval is denied for a patient at the pharmacy and a retrospective ePA process is initiated, the patient – along with the pharmacist and the prescriber – are stuck in limbo. Administrative delays – from the prescriber being unaware a PA is needed, to the pharmacy not knowing a PA is being pursued, to the patient seeing the full cost of the medication – often result in the patient leaving the pharmacy empty-handed.

Brands now have a way to leverage the ePA system to help their patients leave the pharmacy with their prescribed medication. A comprehensive first fill buy-down co-pay program in combination with the ePA process has the potential to solve this problem, based on recent case studies reviewed by ConnectiveRx.[4]

Helping Patients Leave the Pharmacy with their Medications

Co-pay programs are widely used to increase access and adherence for branded and specialty medications. Our market research has shown an average 11.5% lift in prescriptions when such programs are offered.[5] However, co-pay programs are typically available for medications that do not require prior authorization. 

Administrative burdens are a significant hurdle for HCPs and their staff, with 64% of providers saying they alter their choice of brands because of access challenges, including PA.[6] In addition, if they believe brands are only offering co-pay cards after a medication is approved, they are less likely to suggest that medication as their first choice when the risk of abandonment is so great.

For those brands that are willing to “buy down” the first fill of a medication before the prior authorization is approved, the approval process will take place behind the scenes – while patients go home with their medication. This type of co-pay program offers prescribers adequate time to provide necessary information to payers in order to secure PA approvals. Then, if the PA process results in approval, the brand is reimbursed by the insurer for the cost of the first full buy-down – and patients are more likely to refill and stay on the medication, resulting in ongoing revenue for the brand.

The Value of First Fill Buy-Down Programs

ConnectiveRx has tracked ePA initiation status to determine cost vs. revenue. One brand (Brand X) offered a co-pay program that covered the cost of first fills while patients were awaiting PA decisions from their health insurers. Of those, 7,597 refills were subsequently covered as the PAs were approved. Brand X paid out an average of $715.13 for the buy down but just $166.96 for the refills. The buy down co-pay program cost Brand X just short of $10M altogether; the brand was ultimately reimbursed more than $29M from the payers, resulting in a revenue stream of more than $19M on refills alone.[7]

With so many brand launches today focused on specialty medications, the current trends in PA are not going away. The most critical contributor to both patient health and brand revenue is ensuring patients leave the pharmacy with their prescribed medication in hand. Combining ePAs with co-pay programs covering the first fill of medications that require PAs allows sufficient time to overcome administrative hurdles while enabling patients to immediately start therapy. This creates a win-win for brands and the patients who use their medications.

[1] American Medical Association, “2020 AMA prior authorization (PA) physician survey,” April 2021.

[2] American Medical Association, “2020 AMA prior authorization (PA) physician survey,” April 2021.

[3] https://www.ama-assn.org/practice-management/sustainability/prior-authorization-practice-resources

[4]  Source: ConnectiveRx, Case study for Brand X July 2019 – November 2019; January 2020 – April 2020.

[5] ConnectiveRx EHR analysis of 27 PhysicianCare programs run between January 1, 2016 and December 31, 2018. Measurement is based on de-identified prescription data (written); range 0.09% to 29.05%. The results presented are representative of these programs only; each product situation is unique and future results may differ.

[6] ConnectiveRx patient price transparency research, Nov 2019. n = 70 prescribers exposed to standard insurance scenario ($80 patient out of pocket cost for [blinded medication]).

[7] ConnectiveRx case study for Brand X, July 2019 – November 2019; January 2020 – March 2021.

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