Specialty pharmacy benefits HCV patients, health system

Implementation of an on-site specialty pharmacy by the University of Illinois Hospital Health Sciences System, Chicago, offers a streamlined process for excellent and cost-effective care for patients with hepatitis C virus, according to Michelle T. Martin, PharmD, BCPS, BCACP, speaking in a presentation during the ASHP Midyear 2014 meeting in Anaheim, Calif.

Before 2012, clinicians at the University of Illinois system had to work with nurses and other providers in their outpatient clinics to obtain specialty pharmacy medication approvals, with most of the prescriptions going to external pharmacies that were not associated with the health system. The time that it took to secure medication approval was burdensome and could delay the initiation of treatment. There also were limitations once prior authorizations were obtained.

“Our prior authorizations for HCV medications are often limited to an eight-week time frame,” said Martin, a clinical pharmacist and clinical assistant professor, ambulatory pharmacy, Department of Pharmacy Practice, University of Illinois at Chicago. “So if the patient doesn’t start immediately, the patient may be unable to get all their medication refills in before another prior authorization is needed.”

As a clinical pharmacist, Martin had to spend most of her time before 2012 working with the pharmacy technician in the dispensing pharmacy who assisted with prior authorizations for the in-network patients. Martin also coordinated the out-of-network prior authorizations by herself for more than 70 patients. At that time, patients were being treated with protease inhibitors and additional agents for treatments lasting 24 to 48 weeks.

“There was an enormous amount of paperwork when we were doing all the prior authorizations for in-network and out-of-network patients,” Martin said.

Better care

With the implementation of the on-site specialty pharmacy in 2012, the process became more streamlined, with the specialty pharmacy handling all the prior authorizations for medication approval. Where Martin works, on the clinic side, she no longer had to be concerned with the avalanche of prior-authorization paperwork.

That changed, however, however, as the treatment referrals for hepatitis C patients increased in 2014 following the approvals of simeprevir and sofosbuvir, and the paperwork became too much for the on-site specialty pharmacy to manage.

The health system’s specialty pharmacy decided it could only handle prior authorizations for the in-network patients whose medications would be filled there. Martin again was needed to assist with prior authorizations for out-of-network patients.

She decided to take advantage of the talents of experienced pharmacy technicians and third-year pharmacy students and turned to them for help with the benefit verification and prior-authorization process for in-network and out-of-network patients.

“What sets our specialty pharmacy apart from other specialty pharmacies is the we have access to the electronic medical record [EMR] system. So our specialty pharmacy is always communicating with providers - physician assistants, nurse practitioners, physicians, as well as the clinical pharmacist - making this a seamless process,” Martin said.

How the process works

When Martin receives a referral from a physician designating the start of treatment for a patient with hepatitis C, she evaluates the patient’s chart and the specific treatment for appropriateness and dosing. She forwards a note to the specialty pharmacy, asking for an evaluation of the patient for benefit verification, and then receives a response from the specialty pharmacy - all accomplished through the EMR.

If the patient doesn’t have pharmacy benefits or needs assistance with high co-pays, she refers the patient to the health system’s medication assistance program.

Often initial requests for medication are denied by the patient’s insurance company and have to be appealed. Martin will write letters of medical necessity and send them back to the specialty pharmacy through the EMR system. She also helps patients who are out-of-network, with pharmacy students assisting with prior authorizations. She gets doctor signatures and letters of medical necessity.

“My students will call the patients to help coordinate with them to make sure that they have called their outside mail-order pharmacy to register and arrange for a delivery date of the medication once it is approved. They will call patients to make sure they receive it prior to their appointment with me at the clinic,” Martin said.

With additional “free time,” Martin can work one-on-one with patients at treatment initiation and follow-up. She also works closely with the clinicians on appropriate medication prescribing.

In 2014, she has been able to help approximately 350 patients with hepatitis C, thanks to the help of pharmacy technicians and pharmacy students in the clinic and specialty pharmacy.

“We have fewer insurance issues, as the process is more streamlined. We are able to care for more patients and start more patients on treatment, because we have a pharmacist in the clinic able to do patient care as opposed to mostly paperwork,” she said.