How much time does your staff spend dealing with prior authorizations and callbacks by the pharmacy and by patients? Similarly, how often are your patients upset because their prescription was not approved, or the pharmacy did not carry the item? There are many challenges when it comes to prescription medications, which include jumping through hoops with insurers regarding prior authorizations and denials and dealing with pharmacy benefit managers, etc.

In this article, I will discuss some of these key challenges and how my practice has overcome them.

DEALING WITH INSURERS WITH PRIOR AUTHORIZATIONS

One problem that we see in the clinic is that each insurance requires different criteria for qualifying for a dry eye medication — insurances want to see documentation of what the patient has tried. I have no issue with this request; however, our staff has to send medical records proving that the patient has tried a particular medicine first, and we have to provide information that they failed three or more over-the-counter medications, including a gel.

For example, Insurance A requires only one sign or symptom of dry eye to cover the medication as opposed to Insurance B that requires two signs or symptoms plus two diagnostic tests to approve this medicine.

This issue requires standardizing the diagnostic requirements for dry eye and other medical conditions amongst all insurance plans, including Medicare. Some insurance companies are more technologically savvy and offer an online prior authorization form to expedite the already tedious process.

Meanwhile, other companies will send you a prior authorization form that has to be faxed. If your staff has extra time, they can search online for the prior authorization form and then they will have to print it, fill it out and fax it to the insurance company. These steps take time and create frustration for staff and patients alike. It can require a full-time employee just to manage the prior authorizations.

The correct diagnosis code also has to be entered correctly and is different for two medicines. For instance, Cequa (cyclosporine 0.09%, Sun Ophthalmics) requires a diagnosis code for dry eye syndrome or keratoconjunctivitis sicca as opposed to cyclosporine 0.05% (Restasis, Allergan), which is only indicated and approved for keratoconjunctivitis sicca, not specified as Sjögren’s syndrome. Your staff would learn this nuance with time, but the point is that there are too many hurdles for us to take great care of our patients.

Compounded cyclosporine might be the solution. This would reduce the encumber of callbacks and wasted time by the patient and staff waiting for prior authorizations of these branded drugs.

UNDESIRED SWITCHES FROM BRANDED TO GENERIC

Oftentimes, medications are not covered by insurances, especially when it is a branded medication. As a physician, you have the option to select no substitutions. If you have a strong rationale for the medication that you prefer for your patients, then simply select “Brand only.”

Unfortunately, this comes at a price for the patient. We have all had patients with poorly controlled uveitis who responded better to a branded medicine than a generic. For example, you prescribed 1% prednisolone acetate for a uveitis patient and their inflammation did not improve as much. You switched to prednisolone acetate 1% (Pred Forte, Allergan) and the inflammation improved faster or to a difluprednate ophthalmic emulsion 0.05% (Durezol, Novartis).

As MDs, we have to balance efficacy with affordability for the patient. We have to choose the most efficacious medication at the lowest price for our patients. In some cases, branded medicine might be preferred, which unfortunately results in a higher price.

At other times, we have seen that pharmacy managers change certain glaucoma medications or steroid drops that we prescribe when we specifically wrote for a designated one. For example, when writing for a branded glaucoma drop, numerous times the pharmacist changes it to a generic medicine. This switch in medicine may only be noticed when the patient returns one month later to re-check their IOP.

Medicine prescription should not be altered when the physician writes for a specified medicine. Again, adding “Branded medicine only” where appropriate can help to avoid this situation.

CALLBACKS BY THE PHARMACY

Pharmacy callbacks are a major issue for staff across ophthalmology. Oftentimes, staff are on the phone during clinic hours with callbacks, which disrupts patient flow and takes time away from the patients who are physically present in the clinic.

Consider having staff do callbacks during the lunch hour or at off times, such as when the surgeon is in the operating room. You could also hire a part-time or full-time staff member to manage the callbacks.

PREVENTING DISTRESSED PATIENTS

It is emotionally draining for our staff to be mistreated by angry patients whose insurances do not cover the medications or that require a prior authorization. Both the patient and staff become upset when the medications are not covered.

We continually work with patients to find alternative medications that are equally efficacious but are more affordable. For example, some patients want us to do mail order prescriptions to save money, so we go the extra mile to help them. In some cases, we write a 3-month prescription on their glaucoma medications, so that they will receive three bottles at the time of their purchase of the medication.

Another time patients often become upset is when they have to drive around town to find their medicine because their primary pharmacy does not carry it or ran out. To avoid these situations, make note of such pharmacies when informed that they typically do not carry that medicine and alert future patients. As a practice, you may have to redirect patients where to go, which may not be the pharmacy closest to their home. However, the longer trip is still in their best interests.

In addition, some patients have given us the incorrect pharmacy information. We then receive a call from the patient or pharmacist, and our team has to call the correct pharmacy and the process starts all over again. Verifying the address with the patient is critical to minimize such additional time away from the practice. Some pharmacies can look up the prescription even if it was sent to another location. Verify the correct address to the pharmacy to minimize additional disruptions in the care of the patient.

THE ROLE OF COMPOUNDED MEDICATIONS

I prescribe OSRX compounded customized medications for nearly all of my patients undergoing LASIK/SMILE and cataract surgeries. Customized compounded medications not only fit their needs but also save these patients and my staff time as they pay the compounding pharmacy directly and do not deal with the hassle of prior authorizations (OSRX, for example, does not accept insurance). In addition, we have never had an issue with any customized compounded medication being out-of-stock.

The costs of compounded eyedrops are significantly lower than branded and even most generics on the market. Patients want affordable options, and compounded medications are my preferred route for my surgery patients. Since using these drops for nearly 2 years, I have only seen several rebound iritis cases and I have not had any endophthalmitis cases.

Furthermore, there is the issue of and poor compliance because of three separate bottles. We have even had patients accidentally use one of the drops more often than recommended because they were confused as to which bottle to use.

When prescribing combination drops in one bottle, the instructions are simple, and my patients have a very high compliance rate. For example, I prescribe a combo drop for my cataract surgery patients (1% prednisolone phosphate, 0.5 % moxifloxacin and 0.075% bromfenac) that they use three times per day for 3 weeks. When patients are prescribed three separate drops for their cataract surgery, this can be very confusing for some patients, which leads to inappropriate amount of dosing of the medicine. This can potentially lead to ocular irritation or increased risk of infection or inflammation.

Patients love the convenience of these drops and have been pleased that they are affordable, which contributes positively to our premium patient experience. And, because OSRX is cash-pay and does not accept insurance with their compounded drops, my staff is happy (experiencing fewer calls) and has more time to provide even better care for our patients.

CONCLUSION

Many practices have to jump through hoops with insurers regarding prior authorizations and denials, pharmacy benefit managers and deal with callbacks by the pharmacy and the pharmacy not carrying a patient’s medication. Follow these tips to overcome these challenges so that you can make life easier for your practice staff and your patients. OM

Robert F. Melendez, MD, MBA, is the founder/CEO of Juliette Eye Institute in Albuquerque, N.M.
Disclosures: Dr. Melendez reported relationships with Allergan and Ocular Science (OSRX is an affiliate of Ocular Science).