For glaucoma specialist Gregory Katz, MD, ensuring patients receive the optimal medication is an ongoing and often daily challenge. After issuing a prescription, Dr. Katz has routinely found the desired medication to not be covered in the patient’s formulary.
Gaining prior authorization can be a time-consuming process and not guaranteed. Further, even with prior authorization, branded medication could be considered too expensive for the patient.
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How can prior authorizations impact patient care?
As a case example, Dr. Katz prescribed a patient Rocklatan only to be told the medication was not covered under the patient’s current plan and was, therefore, denied. He later received a letter informing him that he must first try substituting timolol, brimonidine, and dorzolamide. Although the patient was already on these classes of medications, an initial attempt at prior authorization was rejected.
The second prior authorization was eventually approved, but the medication was still going to cost the patient over $200 a month. This situation led to one frustration after another and took up valuable practice and staff time. Recognizing this common dilemma, pharmaceutical companies can provide a novel solution by offering individuals direct-to-patient purchasing.
What is direct-to-patient purchasing?
Also referred to as direct-to-consumer (DTC), direct-to-patient medication sales is an innovative approach to putting prescription drugs in the hands of the patients. In this model, manufacturers sell directly to consumers through licensed specialty pharmacies, potentially bypassing traditional pharmacies and insurance pre-authorizations.
The price for the medications is set by the manufacturer. Physicians supply electronic prescriptions, which are then filled and can either be picked up by or delivered directly to the patient.
Direct-to-patient purchasing pioneers
Within ophthalmology, Sun Pharmaceuticals was the first to enter the direct-to-patient arena with their Xelpros Xpress program, which offered direct patient purchasing of Xelpros (a benzalkonium chloride-free latanoprost formulation, 0.005%) through two affiliated pharmacies, CapstanRx Pharmacy, and Transition Pharmacy. Of note, Xelpros is currently not available in the US market as it is on indefinite backorder.
Shortly after Sun Pharmaceuticals introduced this program, Novartis launched a similar initiative, My Choice RX, for three branded medications: IOP-lowering Travatan Z (travoprost ophthalmic solution, 0.004%), corticosteroid Durezol (difluprednate ophthalmic emulsion, 0.05%) and Ilevro (nepafenac ophthalmic suspension, 0.3%). To prescribe one of these products, the physician would need to send a prescription electronically to ScriptHero, Novartis's partnering pharmacy.
With the success of these two programs, Dr. Katz suspects other pharmaceutical companies might follow suit.
Benefits of direct-to-patient purchasing
According to Dr. Katz, there are four primary benefits to direct-to-patient purchasing: consistency, convenience, care, and cost.
1. Consistency
Upon being prescribed medication, patients regularly ask Dr. Katz how much the prescription could cost and, due to the many fluctuating factors, he can seldom answer them. Based on insurance coverage, co-pays, deductibles, and such, the price of the medication could vary widely. Under the direct-to-patient purchasing model, he can tell them exactly what the cost might be to them with no variables.
2. Convenience
Direct-to-patient purchasing could offer convenience to both the clinician and the patient.1 Doctors can electronically prescribe the medication, without the need for prior authorization or possibility of rejection. In addition, the patient often might have the option to either pick up the prescription or have it delivered to their door.
By eliminating the need for pre-authorization, call-backs, and disputes, these programs also potentially increase office efficiency, especially from a staffing perspective.
3. Care
Direct-to-patient programs can allow physicians to prescribe the branded medications that could best treat the patient at a reasonable cost. Prior, insurance might have removed a branded version from the patient’s coverage and replaced it with the generic counterpart.
In addition, if upon finding out the out-of-pocket cost, the patient could decide they still cannot afford the medication. Subsequently, these programs allow ophthalmologists to take some level of control back in their prescriptive authority by recommending an appropriate alternative without the hassle of callbacks.
4. Cost
As you will see in the examples below, the out-of-pocket cash price for direct-to-patient pharmaceuticals can often be comparable to or less than the price listed on GoodRx and the medication’s generic equivalent.
Pricing examples from personal practice
Dr. Katz offered some pricing examples from his practice. At the time of this interview, a 3-month supply of Xelpros through the Xelpros Xpress program was $110, approximately $37 per month.
In the case of Travatan Z, the cost was $135 for a 3-month supply, which averages to $45 a month. Durezol and Ilevro came in at $60 for a 1-month supply. After checking pricing on GoodRx in his area, Dr. Katz determined the price for generic travoprost was listed at $52 at CVS and $123 at Walmart.
This meant that a patient using Novartis’ My Choice Rx program could get the branded product for less than the generic product. Similar research revealed this held true for other direct-to-patient medications as well.
In conclusion
With the direct-to-patient medication model, Dr. Katz has been pleased to be able to share with patients exactly how much a medication might cost, as there has been virtually no certainty in the pricing from his past experience.
This garners patient confidence and empowers them to decide on the value proposition of a branded medication over a generic medication. He sees this alternative mode of providing medication as an enhancement to the delivery of the appropriate treatment benefitting both the physician and the patient.
Disclaimer: This content is not intended to cover all possible diagnosis methods, treatments, follow-up, drugs and any contraindications or side effects. Additionally, with respect to prescription medications, it is advisable to check the production information (PI) sheet accompanying each drug to verify conditions of use along with identifying any changes in dosing schedule and contraindications. In reference to insurance coverage, prior authorizations, and medication cost: these factors are subject to change based on carrier guidelines where limitations, copayments, restrictions may apply. The medical opinions and views expressed in this article are those of Gregory J. Katz, MD.
