Automated pharmacy substitution for medications not covered by Medicaid: A model for reducing the burden of prior authorizations in dermatology

Insurance companies use formularies and prior authorizations (PAs) to lower unnecessary drug use and cost. 1 Popatia S. Flood K.S. Golbari N.M. et al. Examining the prior authorization process, patient outcomes, and the impact of a pharmacy intervention: a single-center review. J Am Acad Dermatol. 2019; 81: 1308-1318https://doi.org/10.1016/j.jaad.2019.05.024 Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar In theory, their intended impact is positive—safeguarding against unnecessary and inappropriate care. However, they have been shown to be more burdensome for providers and may not be as cost effective. 1 Popatia S. Flood K.S. Golbari N.M. et al. Examining the prior authorization process, patient outcomes, and the impact of a pharmacy intervention: a single-center review. J Am Acad Dermatol. 2019; 81: 1308-1318https://doi.org/10.1016/j.jaad.2019.05.024 Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar ,2 Carlisle R.P. Flint N.D. Hopkins Z.H. Eliason M.J. Duffin K.C. Secrest A.M. Administrative burden and costs of prior authorizations in a dermatology department. JAMA Dermatol. 2020; 156: 1074-1078https://doi.org/10.1001/jamadermatol.2020.1852 Crossref PubMed Scopus (11) Google Scholar Contrary to their intended impact, studies have demonstrated that PAs may reduce access to dermatology medications for patients. In prior reports, 76% of dermatological treatments were noted to require a PA. 3 Balkrishnan R. Bhosle M.J. Fleischer Jr., A.B. Feldman S.R. Prior authorization for topical psoriasis treatments: is it cost-beneficial for managed care?. J Dermatolog Treat. 2010; 21: 178-184https://doi.org/10.3109/09546630903268247 Crossref PubMed Scopus (9) Google Scholar Medicaid patients may experience significant delays or never receive prescribed dermatology medications due to delays in the PA process, and frequent changes in Medicaid formularies. There is growing evidence showing a negative association between restrictions on medication formularies and medication adherence outcomes. 4 Happe L.E. Clark D. Holliday E. Young T. A systematic literature review assessing the directional impact of managed care formulary restrictions on medication adherence, clinical outcomes, economic outcomes, and health care resource utilization. J Manag Care Spec Pharm. 2014; 20: 677-684https://doi.org/10.18553/jmcp.2014.20.7.677 Crossref PubMed Scopus (53) Google Scholar Additionally, when providers write prescriptions, they may be unaware of medications covered or the least expensive option for patients as formularies frequently change. If providers wrote for the least expensive topical corticosteroid within a potency class, an estimated 450 million dollars could have been saved in 2015. 5 Gupta S. Menge T. LaChance A. Mostaghimi A. The potential impact of same-class substitution of topical steroids on health care spending. J Am Acad Dermatol. 2020; 83: e439-e440https://doi.org/10.1016/j.jaad.2020.07.096 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar