How Payer Processes Can Impact MS Therapy Access: Dr JT Lew

While payer requirements such as prior authorization or step therapy are implemented with the intention of fostering responsible medication use, they can lead to discouragement on the provider and patient side when approvals are delayed. JT Lew, PharmD, MBA, a managed care pharmacist at MultiCare Health System, spoke to the impacts of such policies in the realm of multiple sclerosis (MS).

JT Lew, PharmD, MBA, managed care pharmacist at MultiCare Health System

During a presentation at The American Journal of Managed Care^®’s Institute for Value-Based Medicine^® (IVBM) event in Seattle, Washington, cohosted with Providence, Lew spoke to the challenges regarding medication accessibility in the MS treatment space. In part 1 of this interview, Lew discussed the barriers patients may face in accessing therapies in the MS treatment space.

This interview has been lightly edited for clarity.

AJMC: How do prior authorization and step therapy requirements impact patient access to MS medications?

Lew: Prior authorization and step therapy, from a payer perspective, promote good stewardship and maintaining a healthy supply chain, especially for those patients with the highest disease activity. The patients who have the highest disease activity are at the highest risk for progression. Therefore, high-efficacy products that cost a lot, such as the monoclonal antibodies, are ones we want to reserve for those patients with highly active disease to really reduce their risk of progressing further.

On the other hand, it can be incredibly discouraging for patients to wait for an insurance approval—and worse is risking experiencing a relapse. That could be incredibly painful to the patient. This scenario is especially relevant when switching between insurance plans, because different payers have different criteria on which ones they prefer, which ones they don't prefer. For example, when patients are diagnosed with multiple sclerosis, they can often still be employed, and many patients still have career ambitions and might find a different job. But when they switch that job, employees might not have the same coverage. Also, thinking about the patients who might be on the verge of retirement, switching over from commercial insurance to Medicare brings a whole other set of challenges, too—especially with the cost share aspect.

This is really important, because there have been case reports of patients experiencing relapses with natalizumab and fingolimod when they've discontinued the medication. That's why it's important for insurance plans to do their best to work quickly and swiftly when navigating these prior authorizations and step therapy requirements and reviewing those for these patients, as their risk-free relapse can be much different than what we might see in other disease states, such as something like hypertension or diabetes.

AJMC: In what ways do tiered formularies influence the out-of-pocket costs for patients with MS, and how does this affect adherence to treatment?

Lew: Most medications that are used for MS are on a specialty tier, so there's usually some sort of coinsurance based off the percentage amount the pharmacy expects to be reimbursed at. However, this can adversely affect adherence, because patients might not know what their cost share is until the prescription is physically processed or they get approached by the specialty pharmacy. And I say approached by the specialty pharmacy because these specialty pharmacies are often different from traditional brick and mortar pharmacies or pharmacies that we might see in the community. In our community pharmacies, we can go to the counter and talk to the pharmacist who might be knowledgeable and helping the patient try to find the resources they need to help try to afford their medications. With a lot of these bigger specialty pharmacies, a lot of these conversations are done telephonically or remotely, and that can bring another barrier to access, especially if the patient doesn't necessarily have, for example, cell phone coverage or access to a phone or other social determinants of health, to be able to connect with the specialty pharmacy. So those are some of the ways that these tiered formularies can impact adherence.

AJMC: How can value-based agreements help align the interests of payers, providers, and patients in the management of MS?

Lew: There's lots of different ways I could think of, but in short, I think the goal of an ideal value-based agreement is to lower the total net cost of care for the payer, the providers, and the patients. An ideal case example of this working would be for the available generics and biosimilars that we have in the multiple sclerosis therapeutic area; these medications often have lower list prices than the innovator products that have higher list prices. So, shifting utilization from the higher list price innovator products to the lower list price generics or biosimilars, on paper, would be a win for the payers, providers, and patients to achieve that shared goal of achieving the total lower net cost.