Targeted therapies have changed the cancer treatment paradigm; however, obtaining off-label coverage of these therapies beyond the U.S. Food and Drug Administration-approved indications is challenging and can cause treatment delays.
A study found that the pharmacist can be a “valuable asset” to help patients receive approval for targeted cancer therapies and navigate coverage obstacles. The results of the study were presented by Francheska Ocasio Serrano, BS, CPhT, and Jennifer Espiritu, PharmD, BCOP, both of the Department of Pharmacy at Beth Israel Deaconess Medical Center at Harvard Medical School, at HOPA’s 16th Annual Conference.
Researchers conducted a retrospective analysis of insurance outcomes from March 2019 through October 2019 at Beth Israel Deaconess Medical Center. Researchers used pharmacy intervention records to identify 14 patients who had a pharmacist involved in their insurance approval process. They assessed medication, indication, payer type, initial denial reason, appeal methods, and appeal outcomes.
In 12 instances (86%), pharmacist assistance was retrospectively required for appeals after denial of treatment coverage. Pharmacist interventions included writing letters of medical necessity (n=11; 79%), providing literature to payers (n=2; 14%), and conducting a peer-to-peer discussion on the physician’s behalf (n=1; 7%).
Among the 12 appeals, nine denials (75%) were overturned (primary endpoint). The most common reason for initial insurance denial (secondary endpoint) was absence of a traditional mutation for a targeted therapy (n=5; 42%); other reasons were unfamiliarity of current literature (n=3; 25%), out-of-date coverage policies (n=2; 17%), and “other” (n=2; 17%).
“[Pharmacists] have a unique combination of clinical expertise and practical reimbursement knowledge that puts us in a prime position to ensure patients are able to gain access to necessary medications and challenge unreasonable coverage determinations,” the authors concluded.
Reference
Espiritu J, Ocasio Serrano F. The role of pharmacists in increasing patient access to targeted therapies. Presented at HOPA 16th Annual Conference. March 2020, Tampa, Florida.
