Journal of Clinical Dermatology & Therapy Category: Clinical Type: Retrospective Study

Impact of Prior Authorizations on Topical Dermatological Prescriptions

Jared S. Kahn1,2, Anh Lam2, Michael Lavin2 and F Clarissa Yang1,2*

1 Tufts University School Of Medicine, 145 Harrison Ave, Boston, MA 02111, United States
2 Department Of Dermatology, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, United States

*Corresponding Author(s):
F Clarissa Yang
Department Of Dermatology, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, United States
Tel:+1 6176360156,
Fax:+1 6176369179
Email:fyang1@tuftsmedicalcenter.org

Received Date: Aug 27, 2022
Accepted Date: Aug 30, 2022
Published Date: Sep 06, 2022

Introduction

Prior authorizations (PAs) present cost-saving for insurance companies but increase administrative time and cost burden for practices and delay treatment for patients. When PAs are required, only 52.8% of patients initiate treatment, dropping to <15% with PA denial [1]. Expensive copayments are also barriers. Patient Assistance Programs (PAPs) from manufacturers may reduce copayments in cases of inadequate insurance. However, PAPs are not available for most topical non-biologics, may involve multi-step PA processes, and may have limitations on number of dollars or times used per year. 

In the United States, patients with high medication costs can obtain coupons through prescription price tracking companies such as GoodRx [2]. Drug coupons can be obtained irrespective of patients’ insurance coverage, financial status and can be applied to any medications. GoodRx prices can be found on the company’s website while some electronic health record systems even display the GoodRx price when prescribing. However, the coupons are pharmacy-chain specific, thus the coupon and prescriptions must be sent and filled accordingly. Since all patients are eligible for discount coupons, are PAs still worthwhile?

Methods

We performed a retrospective review of prescribed non-biologic topical dermatologic medications, PA requests, and copayments at Tufts Medical Center (TMC) from 10/1/2019 to 10/1/2020. This study was approved by the TMC Institutional Review Board.

Results

15,438 non-biologic medications were prescribed, of which 10,879 were topical prescriptions and 590 (5.4%) required PAs. PAs were performed by our central pharmacy team which typically yields a higher approval rate of 72.4% [3]. Pharmacy technicians at TMC spend on average 30 minutes processing, submitting and following up on each non-biologic PA. Utilizing national mean wage plus benefits for a pharmacy technician of $22.25/hr, we estimate each PA cost as $11.13 [4], excluding appeals and peer-to-peer communications requiring more costly physician time. For the patient, paying a co-pay is almost always cost beneficial except for three medications: hydroquinone, benzoyl peroxide, and imiquimod for which the coupon price was less than the co-pay price (Table 1). 

Medication Class

Rx

PA

PA/Rx

PA/all non-biologic PAs

Approved PAs

Avg copay price

Avg drug coupon price

No.

No.

%

%

No.

%

Topical Retinoid/Acne/Rosacea/Lightening

Adapalene

133

13

9.8

1.6

7

53.8

$6.00 (0.1%)

$12.29 (0.1%)

$26.74 (0.3%)

$52.29 (0.3%)

Adapalene/Benzoyl peroxide

5

2

40.0

0.2

1

50.0

$24.33

$34.45

Azelaic acid

151

15

9.9

1.8

10

66.7

$16.72

$67.91

Benzoyl peroxide

449

7

1.6

0.9

7

100.0

$7.12

$6.79

Benzoyl peroxide-clindamycin

46

5

10.9

0.6

0

0

$7.31

$28.84

Brimonidine

3

1

33

0.1

1

100.0

$55.00

$504.47

Dapsone

99

8

8.1

1.0

6

75.0

$14.51

$139.74

Ivermectin

22

7

31.8

0.9

5

71.4

$30.50

$138.94

Hydroquinone

124

1

0.8

0.1

0

0.0

$36.38

$19.99

Metronidazole

233

1

0.6

0.4

0

0.0

$5.66

$32.76

Oxymetazoline

17

4

23.5

0.6

1

25.0

$45.00

$443.80

Sulfacetamide

62

2

3.2

9.2

0

0.0

$8.33

$27.16

Tazarotene

33

9

27.3

1.1

8

88.9

$35.21

$79.04

Tretinoin

1109

174

15.7

21.1

142

81.6

$14.70

$24.09

Total

2486

249

10.0%

30.2%

188

75.5%

 

 

 

 

 

 

Topical Steroids

 

 

 

 

Aclometasone

65

0

0.0

0.0

-

-

$5.96

$11.15

Betamethasone

1156

20

1.7

2.4

9

45.0

$5.94

$16.03

Clobetasol

546

40

7.3

4.9

28

70.0

$6.49

$17.35

Desonide

138

9

6.5

1.1

5

55.6

$4.66

$15.81

Desoximetasone

10

2

20

0.2

2

100.0

$3.33

$22.36

Fluocinolone

160

6

3.8

0.7

6

100.00

$11.21

$23.74

Fluocinonide

246

9

3.7

1.1

6

66.7

$2.67

$12.75

Halobetasol

114

9

7.9

1.1

7

77.8

$10.22

$16.20

Hydrocortisone

896

2

0.2

0.2

1

50.0

$3.53

$5.84

Mometasone

205

0

0.0

0.0

-

-

$4.93

$9.23

Triamcinolone

1066

5

0.5

0.6

5

100.0

$3.73

$4.46

Total

4542

102

2.2%

12.4%

69

67.6%

 

 

 

 

 

Topical Antibiotics/Antifungls

 

 

 

 

 

Ciclopirox

83

7

8.4

0.9

4

57.1

$4.24

$22.45

Clindamycin

1043

19

1.8

2.3

16

84.2

$7.16

$31.87

Econazole

168

1

0.6

0.1

1

100.0

$4.37

$10.50

Efinaconazole

5

1

40.0

0.2

0

0.0

$40.00

$641.72

Erythromycin

15

1

6.7

0.1

1

100.0

$13.07

$19.45

Ketoconazole

1092

1

0.1

0.1

0

0.0

$3.93

$11.18

Mupirocin

311

0

0.0

0.0

-

-

$4.22

$8.52

Total

2717

30

1.1%

3.6%

22

73.3%

 

 

 

 

 

Topical Immunomodulators/other

 

 

 

 

 

Calcipotriene

93

12

12.9

1.5

9

75.0

$6.76

$76.39

Calcipotriene-betamethasone

19

5

26.3

0.6

2

40.0

$3.57

$167.88

Crisaborole

106

34

32.1

4.1

21

61.8

$16.80

$669.46

Fluorouracil

185

1

0.54

0.12

1

100.0

$18.53

$45.50

Imiquimod

36

0

0.0

0.0

-

-

$20.59

$15.74

Pimecrolimus

136

49

36.0

6.0

36

73.5

$12.28

$84.91

Tacrolimus

559

108

19.3

13.1

83

76.9

$17.87

$51.29

Total

1134

209

18.4%

25.4%

152

72.7%

 

 

Table 1: Prescription rates, prior authorization rates and copayment prices of non-biologic topical agents in a 12-month period.

OTC

   GoodRx< Copayment
   GoodRx> Copayment but < WTP
   GoodRx> Copayment and > WTP

 

In a 2012 study, patient median Willingness to Pay (WTP) for dermatology prescriptions to control disease was reported as $30/month for all income groups [5]. Accounting for an average inflation rate of 1.94%/year, this equates to $35.75 in 2021.Using WTP as a threshold, 62.9% of the topical medications requiring PAs had coupon prices below patient’s median WTP. The average price difference between co-pay and discounted coupon rate was $10.09, less than the PA cost. Of note, 100% of topical steroids were within the WTP with an average price difference of $8.39. Limitations include the retrospective design, single academic center and drug prices subject to market fluctuations.

Discussion

Overall, when the coupon price is less than the copayment, patients and the practice would benefit by avoiding treatment delays and PA costs through use of a coupon. If the coupon price greatly exceeds the copayment, completing the PA or switching to a covered prescription is ideal. However, additional consideration is needed when the coupon price is below the WTP. Although the PA will save the patient money and allow them to pay towards their deductible, the lack of guaranteed approval, delay in filling, risk of non-adherence, time and cost to the practice, and potential decline in patient satisfaction should be considered. Conversely, notable downsides of GoodRx are continuous price and vendor fluctuations, requiring a search at the time of each prescription. Thus, if GoodRx pricing is not embedded within the EHR workflow, it may still cause practices extra time during critical, high volume, in-clinic time which would need to be considered. Evaluating common topical medication drug-coupon prices compared to co-pay costs may help practitioners decide how best to manage their practices.

IRB Approval Status

Reviewed and approved by Tufts Health Sciences Institutional Review Board; approval# 00001160

References

Citation: Kahn JS, Lam A, Lavin M, Yang FC (2022) Impact of Prior Authorizations on Topical Dermatological Prescriptions. J Clin Dermatol Ther 8: 0103.

Copyright: © 2022  Jared S. Kahn, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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