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Clinical Quality and Savings: National CooperativeRx Specialty Prior Authorization Program

As a member-owned Cooperative that strives to provide services that enhance the value and quality of members’ pharmacy benefits, a decision was made to bring specialty prior authorizations (PA) in-house, effective January 1, 2023. As with any major project, it required a lot of hard work, patience, and persistence. Now, over one year into the program, we have reviewed over 13,000 cases, helping our member groups achieve significant savings and elevate the level of clinical quality and customer service. This has been accomplished through improvements in patient, provider and member communications, criteria enhancements, and ownership in the case review process.

One of the goals of the in-house Specialty Prior Authorization Program is to improve the patient experience. When a patient or provider calls the National CooperativeRx Specialty Prior Authorization department, a prior authorization coordinator answers – no telephone prompts or waiting on hold. Most concerns are handled with one call, with pharmacists readily available in case clinical expertise is required. One such occurrence was when a frantic patient called in need of an urgent prior authorization for Spravato, a drug used to treat resistant depression with suicidal ideation. The patient spoke with our PA Coordinator, who demonstrated empathy and a sense of urgency by reaching out to the patient’s clinic to retrieve the necessary paperwork and alerting the pharmacist to review it immediately. The case was initiated, reviewed, and approved within hours and the medication was shipped out the same day. The patient called back to express her gratitude that the situation was handled with kindness and urgency. Unfortunately, while we aim to provide exemplary service and member satisfaction, PA denials come with the territory of a prior authorization program, and disappointed patients sometimes follow. When we are approached by a member group with an escalated prior authorization matter, we strive to address the concern promptly and directly, seeing these as opportunities for education, high-touch customer service, and our own growth.

A second goal of the National CooperativeRx Specialty PA Program is to address a steep trend in utilization and spend in psoriasis drugs. This is being accomplished with a multi-pronged approach: Implementation of enhanced criteria and more thorough case review. In January of 2023, the Cooperative implemented CVS Caremark’s enhanced psoriasis criteria, designed to ensure cost-effective, guideline-based therapies are used before more expensive biologics. This change was made in tandem with the start of the National CooperativeRx Specialty PA Program and has resulted in savings of $1.8 million in specialty psoriasis drugs for our member groups. Our clinical team is currently working toward further patient-centered enhancements in the psoriasis space that would simultaneously provide additional savings.

The final overarching goal of the National CooperativeRx Specialty PA program is to demonstrate ownership in the clinical review process. Our team handles each case as if the patient and the dollars were our own. However, sentimental it may sound, this approach has led to reduced spend and improved quality of care. One example of this was in a request for an injectable cholesterol medication. A physician submitted a “continuation of therapy” request for the drug, yet there were no claims on the patient’s profile to corroborate the patient was already on therapy. The National CooperativeRx pharmacist reviewer requested the prescriber submit a “new to therapy” request instead, along with supporting documentation. On receipt of the completed prior authorization form, it was determined the patient did not actually meet criteria and the pharmacist suggested a statin medication instead. The savings associated with this careful review and additional effort totaled $6,000/year.

In addition to cost savings, high-quality clinical reviews contribute to a more efficient process when fewer cases end in Federal External Review. This is the final level of appeal as governed by the Affordable Care Act and is used when a provider disagrees with a prior authorization denial. In contrast to the CVS Caremark process, our team applies clinical judgment at all levels of review, which may allow a request to be approved at a lower level of review. Each time a request goes to appeal, it extends the time the patient is waiting for a decision, and thus, waiting for care. With National CooperativeRx in the Specialty PA driver’s seat, the number of cases that go to Federal External Review has decreased by 50%, and of those cases, only 23% are approved. Prior to 2023, the rate of approval for these cases was over 60%. Combined with our average case turnaround time of 1.92 days, these are indicators the National CooperativeRx team is making sound and timely decisions for plan participants.

Overall, a conservative estimate of savings and cost avoidance with the Specialty PA Program is greater than $4.5 million through quarter 3 of 2023, including over $300,000 in PA and appeals fees that Cooperative members previously paid to CVS Caremark. 2023 was a year of learning, growth, and achievement for the Clinical Team at National CooperativeRx. The team is enthusiastic about 2024 as we continue to find new ways to bring value to our member groups.

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