The rising costs of prescription medications are a pressing issue for many patients, impacting not only those who are uninsured or underinsured but also the healthcare professionals who manage their care.
Recent discussions have highlighted the challenges posed by escalating healthcare expenditures, particularly in eyecare.
Factors contributing to high prescription drug costs
Several factors contribute to the high costs associated with medical treatments, including:1
- Lack of Central Negotiation: Unlike many other countries with a central body to negotiate drug prices, the US system includes numerous individual health plans, diminishing the bargaining power of consumers. Although the Inflation Reduction Act of 2022 allows Medicare to negotiate prices for specific high-cost drugs, the vast majority of privately insured individuals lack similar protections.
- Absence of Price Controls: Other nations impose caps on drug sales growth, whereas the US market does not have comparable regulations, allowing companies to set initial prices without restriction.
- Market Price Reflection: Pharmaceutical companies assert that drug prices reflect their therapeutic value and the costs of clinical trials, but a clear connection between research funding and pricing remains unclear.
- Incentives for Higher-Priced Drugs: Pharmacy benefit managers (PBMs) earn more from higher sticker prices through rebate arrangements with manufacturers, creating a financial incentive for the promotion of expensive medications over more affordable alternatives.
- Fragmented System: The US healthcare system is complex and fragmented, often benefiting middlemen like PBMs rather than patients or providers. Manufacturers receive only a fraction of the total spend on drugs after discounts are applied.
- Patent Manipulation: Companies can extend patent protections through minor modifications to drugs, preventing generics from entering the market and maintaining higher prices for longer periods.
The impact of high prescription drug costs on ophthalmic care
In clinical practice, optometrists often prioritize prescribing the best therapies available. However, the reality of patient finances can limit the treatments prescribed, especially for conditions like dry eye disease (DED). Despite having insurance, patients frequently encounter barriers such as strict formularies and prior authorization requirements, which can restrict access to new and more effective therapies.
Prescribing can be particularly difficult due to the high costs of certain medications. Eyecare providers may find themselves prescribing less effective alternatives or generics, which may not work as well for all patients. Such decisions often arise from the need to navigate insurance limitations rather than a clear clinical rationale.
As an optometrist who specializes in treating dry eye patients, medication costs significantly impact my prescribing habits. When choosing a treatment, I have to balance efficacy with affordability. Newer medications often utilize advanced technology that can lead to better and faster clinical improvement, but their high cost can be prohibitive—particularly for patients with inadequate or no insurance coverage.
Additionally, patients with chronic dry eye typically need to use these medications long-term. Higher medication costs can lead to non-compliance with medications or less frequent dosing to stretch out their supply. This compromises the treatment efficacy and therefore extends patient discomfort.
Addressing prior authorizations and other challenges
Efficient management of prior authorizations is crucial. Many practices designate specific staff members to handle these requests, ensuring timely submission and follow-up. A well-coordinated team can facilitate the process, minimizing delays in patient care.
Tips for navigating prior authorizations for dry eye medications
To successfully navigate the prior authorization (PA) process, several crucial steps must be followed. It begins with thorough documentation of the patient’s medication history, including both over-the-counter (OTC) products and prescription medications previously taken.
This documentation clarifies to the insurance company why coverage for the new medication, particularly if it's a non-formulary drug, should be approved. Most major insurers require evidence of prior trials and failures with multiple dry eye treatments and/or OTC artificial tears before approving higher-tier medications.
In addition to detailing past medication failures, including any specialized tests or treatments performed, can significantly bolster your PA request. Corneal staining, tear break-up time (TBUT)/Schirmers, or the use of punctal plugs should be documented on the PA. Mentioning ongoing symptoms, such as persistent dryness despite the use of warm compresses or lid hygiene wipes, can also enhance the chances of approval.
How to optimize the prior authorization process
Many clinicians now use electronic prescribing systems, which streamline the PA initiation process. For instance, in our office, when a prescription is sent to the pharmacy, any required PA is managed through our ePA system, CoverMyMeds.
Sending these dry eye prescriptions to specialty pharmacies like PhilRx or BlinkRx also helps to smooth out the overall PA process for staff members and the patient. Once this process has been started, this is where the previously gathered documentation becomes vital.
Having a dedicated team member manage the PA process can help minimize errors in submission. It’s important to carefully review the PA form and ensure all necessary information is completed accurately. Since the pharmacy typically initiates the PA, they may prefill certain fields like dosing, form, quantity and certain demographic fields. It’s critical to verify that this information aligns with the prescribed medication.
For example, if a dry eye medication is packaged in vials, a quantity of 60 with an incorrect dosage form of milliliters will likely result in a denial. Another key aspect to check is the "days supply." Insurance companies typically require that the PA not exceed a 30-day supply; submitting for a 180-day supply almost guarantees denial.
Finally, attaching or completing any clinical documentation is crucial for a successful PA submission. Insurers may request a copy of the patient's chart or ask specific questions about previous treatment failures and OTC medications used. Being detailed is crucial; simply stating “past use of artificial tears prn” is insufficient. Instead, specify the exact OTC drops or prescription medications used, along with the dosing schedule the patient followed and for how long. The more detail provided, the better the outcome.
Takeaways on prior authorizations for dry eye medications
The prior authorization process as a whole requires close attention to detail at every step, from comprehensive documentation of the patient’s medication and treatment history to careful review of the PA form itself. By ensuring that all relevant information is accurately provided, including specific treatments and their outcomes, healthcare providers can significantly improve the likelihood of approval for necessary medications.
Having a dedicated team member overseeing this process can further reduce errors and streamline submissions, ultimately enhancing patient care. By investing the time and effort upfront, clinicians can navigate the complexities of insurance requirements more effectively, leading to better treatment outcomes for their patients.
For a deeper dive into how optometrists can optimize the prior authorization process check out Pearls for Navigating the Inevitable Hurdle of Prior Authorizations.
Correct coding can be critical for dry eye disease
Most clinicians tend to use the identical ICD-10-CM code for all of their dry eye patients, i.e., H04.123 (dry eye syndrome of bilateral lacrimal glands). While appropriate in some cases, this code may not be specific enough to warrant prior authorization approval.
In such cases, it may be necessary to include additional or more specific codes that are consistent with the individual product’s indications. For example, this might include H02.88 (meibomian gland dysfunction), H16.223 (keratoconjunctivitis sicca), H16.143 (superficial punctate keratitis), or H18.899 (persistent epithelial defects).
Nicolas Trodella, MBA:
I have found that H16.223 and H16.143 tend to be the best dry eye codes for getting these medications approved. I always suggest to Dr. Garlich to try to use H16.223. Something else I will do is use the H16.223 as the primary diagnosis and then a meibomian gland dysfunction code as a supplemental code—as long as both issues are present on clinical exam.
Patient assistance programs (PAPs) for DED
To help patients manage costs, pharmaceutical manufacturers offer various patient assistance programs.
Patient assistance programs can provide:
- Free samples for patients initiating therapy
- Copayment assistance through savings cards
- Support for navigating prior authorization processes
- Access to centralized online pharmacies for direct shipping and reduced costs
- Reduced or no-cost medications for qualifying individuals based on income
Understanding available PAPs is essential for helping patients afford necessary treatments. Patients on government-sponsored healthcare plans, such as Medicare, are often unable to use certain assistance programs or coupons unless they elect not to use their policy drug plans.
Many pharmaceutical companies have programs in place in case the PA is denied. Oftentimes if you submit a PA for one of these medications and the PA is denied, there is a cash price option for patients for a 30-day supply, usually ranging from $79 to $89.
Key tools and resources for DED-related PAPs
Several resources can assist both patients and providers:
- PhilRx: PhilRx is a digital hub platform that helps to streamline medication access for both patients and providers. The platform empowers retail and specialty-lite manufacturers with an alternative channel solution that can help to improve patient access and maximize covered dispenses. With PhilRx, physicians can submit prescriptions directly through their EHR system, or they can fax the prescription if needed.
- Once PhilRx receives the prescription, they immediately initiate communication with the patient via text messaging. Once the patient opts in and confirms their information, they are enrolled in the program, with no apps to download.
- PhilRx will then determine if the patient is eligible for copay support, an adherence program, or any of a number of different offerings for the medication in question. Most importantly, they will determine if a prior authorization is required, and if so, they can initiate the process using the CoverMyMeds platform (see discussion below).
- With regard to dry eye treatment options, PhilRx currently helps provide access to the following medications: Cequa (cyclosporine 0.09% ophthalmic solution), Tyrvaya (varenicline solution 0.03 mg nasal spray), and Vevye (cyclosporine 0.1% ophthalmic solution). PhilRx even provides free home delivery for patients who utilize their service.
- BlinkRx: Like PhilRx, BlinkRx is a digital pharmacy service operated by Blink Health Administration, LLC. It can connect patients with a wide range of medications via manufacturers who partner with the company’s website.
- In terms of dry eye treatment options, both Xiidra (lifitegrast 5% ophthalmic solution) and Miebo (perfluorohexyloctane ophthalmic solution) are accessible at the lowest possible price through this platform. Once BlinkRx receives the doctor’s prescription (via E-prescribe or fax), they utilize a text platform to communicate directly with the patient.
- Their hub network obtains and analyzes the patient’s insurance to determine their copay and deductible, assists in obtaining additional coverage for the prescribed medications whenever available, and also provides free home delivery.
- Team pharmacists can help address any patient questions and also assist with refills and reminders to help ensure better compliance. BlinkRx can even provide support for those who may require a prior authorization.
- SimpleFill: SimpleFill is another unique nationwide advocacy service that utilizes available PAPs offered directly through various pharmaceutical companies. They can also research additional assistance programs and apply for them on behalf of patients, accessing any potentially available funding, including the Social Security Extra Help Program for eligible individuals.
- Patients must apply directly to SimpleFill, who in turn gathers both their personal and their physician’s information in order to determine their eligibility (a process that requires 3 to 5 weeks in most cases).
- Once approved, SimpleFill maintains, manages, and services the patient's medications. DED products that can be accessed through this program include Restasis (cyclosporine 0.05% ophthalmic emulsion), Xiidra (lifitegrast 5% ophthalmic solution), and Miebo (perfluorohexyloctane ophthalmic solution).
- CoverMyMeds: Founded in 2008, CoverMyMeds is a subsidiary of the McKesson Corporation. It is essentially a healthcare software company that assists patients in obtaining their medications by automating the prior authorization process and connecting the healthcare network.
- CoverMyMeds connects to more than 500 electronic health record systems (EHRs), 50,000 pharmacies, and 900,000 providers. In addition, it offers solutions for medication access, affordability, and adherence, while also providing access to specialty therapies and case managers for high-touch support services.
Other services commonly used by patients are GoodRx and SingleCare.
Conclusion
Our role as healthcare providers has expanded in this era of high-cost medications. Today, we cannot simply prescribe the medication to our patients and assume it will be filled and utilized. Instead, we must also take an active role in ensuring that our patients can obtain these medications, either through their insurance provider or another means, such as a PAP.
Understanding and proactively addressing these issues helps to enhance patient care and expedite desired therapeutic outcomes while also helping to mitigate the financial burden of some DED therapies. By openly discussing and exploring the various resources available, optometrists can improve patient access to these essential medications.
