Why a public employee health plan sponsor ultimately rejected their PBM’s prior authorization criteria for multiple sclerosis

Renee Rayburg, RPh
Sharon Phares, PhD, MPH
August 15, 2020

To reduce costs, pharmacy benefit managers (PBMs) and plan sponsors often implement utilization management (UM) strategies, such as prior authorizations (PAs) and step therapies, within the therapeutic classes responsible for their highest-cost members. (We discuss these practices in more detail in part one of this series.)

Initially, this plan sponsor, which represents a significant number of public employees, didn’t question their PBM’s PA criteria for multiple sclerosis (MS). The criteria required trial and failure of step therapies, as well as disabling symptoms, before patients could progress to preferred therapies.

However, after attending a conference session in which a neurologist and MS patient discussed the importance of access and timing for the right therapies, the plan sponsor decided to take a second look at the PA criteria for their MS members. They had learned that in the treatment of MS, time is important, and they recognized that any delays in optimal treatment could contribute to a loss in brain volume for their affected members.


How PA requirements affect member access

Although the plan sponsor’s formulary included preferred therapies for MS, patients needed to meet the PA requirements to access them.  Requirements included a diagnosis of relapsing/remitting multiple sclerosis, plus trial and failure of multiple step therapies, in addition to one of the following factors:

  • Two disabling relapses within 12 months
  • An observable increase in disability over six months
  • Loss of ability to walk for longer than six months

After learning that treatment delays could negatively impact patients with MS, the plan sponsor began questioning how their MS members were affected by the PA requirements.


Balancing health outcomes and financial implications

The plan sponsor turned to their PSG team to better understand:

  • Are the prior authorization criteria consistent with evidence-based guidelines for the treatment of MS?
  • Are criteria requiring trial and failure of previous therapies contributing to treatment delays for members?
  • What medical consequences may result from treatment delays?
  • Is the current PA process providing value to the plan?


Putting member needs first

The PSG team, which includes clinical pharmacists, benefit consultants, financial experts, and research scientists, helped model and analyze the effect of any changes to the prior authorization process. Ultimately, the plan sponsor determined that restrictive prior authorization criteria risked disease and disability progression for their MS members and could not be justified. They felt strongly that members should have timely access to multiple sclerosis treatments to give them the best chance for optimal treatment, so they removed any requirement for worsening of symptoms in order to speed access to preferred therapies.


Are you a plan sponsor who wishes you could ask Renee Rayburg, RPh and Sharon Frazee, PhD, MPH how you can most effectively manage PAs? Receive their advice in your inbox today!


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In the next post in this series, we will also look at the option of carving out your PA process to manage it separately from your PBM contract.

Renee Rayburg helps lead Artemetrx services in Clinical Consulting with more than 30+ years in pharmacy and medical benefit management to support our health plan sponsors, providers, and patients.  Her thought leadership and passion for specialty pharmacy continues to influence the market, including important changes to specialty vendor clinical management products for the betterment of clients.

Sharon Phares, PhD, MPH, is the Senior Vice President of Research for PSG and an Assistant Adjunct Professor of Clinical Pediatrics and Assistant Adjunct Professor of Internal Medicine with Washington University in St. Louis. Prior to joining the PSG, Sharon was Vice President of Research and Analytics at Express Scripts where she led research strategy and execution for one of the largest PBMs in the nation. She has also held leadership roles in health and economic outcomes research, survey design, pilot and program design and evaluation, analytics and research consulting, advanced analytics, and the development of predictive models at Walgreens, LabCorp, and Landacorp. She was an instructor at North Carolina State University and provided evaluation research for various state and local government agencies before joining the private sector.