Understanding Prescription Pathways for Biologic Medication Therapy

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Executing evidence-based medicine in the U.S. is challenging, especially utilizing high-cost medications in rheumatologic care. As patients trust their clinicians to be their medical experts, clinicians must trust their care team members to be experts at implementing the care plan. A clinician’s knowledge of human anatomy and physiology is the foundation to understanding pathophysiology. From this knowledge base, clinicians can diagnose and choose treatments or solutions.

This concept can be applied to navigating the complex journey of a self-administered biologic or high-cost small-molecule prescription. Having an understanding of the third-party establishments involved allows us to understand when a pathogenesis has occurred in a prescription pathway and, in turn, know how to react or adapt solutions to ensure treatment success.

This topic will be discussed during a concurrent session at the 2016 ACR/ARHP Annual Meeting on Monday, Nov. 14, 2016, from 7:30–8:30 a.m.: Biologic Therapy: Prescription, Prior Authorization and Beyond. Below, you’ll find some of what will be presented:

Understand the Landscape

The major industries influencing the prescription pathway are pharmacy benefit management companies, pharmaceutical companies and specialty pharmacies. Competitions in the industries create variations in prescription pathways. The intent of each organization may be decent, but the complexity of multiple self-serving initiatives continually creates new barriers to the execution of the care plan from the patient’s and provider’s viewpoints. Patients and clinicians may perceive these complexities as complete roadblocks outside of their control.

Although legislation may be necessary to regulate third-party industries affecting patient care, waiting around for this to happen is not in the best interest of our patients. There is a major need to educate our care team members on these third-party industries so we can identify the barriers and implement proactive practice solutions to increase the probability of treatment success.

Rheumatology team members who understand the third-party landscape will be best prepared to execute care plans utilizing self-administered biologic and small-molecule therapies. Transparent education of the industries dictating access and distribution policies will increase awareness and understanding, and provide a foundation for proactive practice solutions.

The Players

A pharmacy benefit management company is a third-party administrator of prescription drug programs for commercial health plans, self-insured employer plans, Medicare Part D plans, the Federal Employees Health Benefits Program and state government employee plans. The most common pharmacy benefit management companies you will encounter are Express Scripts, CVS Health (formerly CVS Caremark) and United Health/OptumRx/Catamaran; these companies have an approximate 80% share of the market.¹