Utilization Management is a practice by health coverage payers, such as insurance companies and government programs, of requiring special authorization when a medication is prescribed before the drug formulary of that plan will cover it for a patient.
Utilization Management efforts take many forms, including required step therapy, requirements for generic prescription, and restriction of some prescriptions to certain types of providers.
Prior Authorization (PA) is the practice of restricting access to prescribed medications by insurers or payers based on certain criteria. This is accomplished by requiring that a prescription medication receive special approval by the insurer prior to being filled by the pharmacy. Prior Authorization properly used can help direct patients to appropriate treatments. Unfortunately, prior authorization is increasingly being used as a tool by insurers to slow or stop the use of high-cost medications, even when they are the standard of care for that condition. Prior Authorization restrictions on HIV and HCV medications is a serious and growing issue for both HIV providers and patients.
For patients living with HIV prior authorization requirements can mean unnecessary delays in getting the medications they need to manage their health condition.
Successful HIV drug therapy involves the prescription of complicated cocktails of drugs. Individual response to antiretroviral treatment is not always equal. HIV patient response to medication can vary widely based on such things as age, gender, race, and ethnicity. Specific patient indicators inform provider decisions on which course of treatment to prescribe.
The virus responds to particular treatment regimens in different ways due to its inherent ability to develop drug resistance rapidly in different patients so that the optimal treatment for one person may not be the same as for another. HIV patients on ARV treatment require close monitoring for effectiveness, tolerability, and drug resistance.
Unlike with many other diseases, when HIV patients have disruptions in their medication regimens, drug resistance occurs, often rendering that medication no longer effective as a course of treatment. Strict adherence to the treatment regimen is essential to its effectiveness.
Patient adherence can also be dependent on the individual tolerability of particular drugs. ARV treatment can result in significant side effects for some patients. Tolerability and mitigation of side effects can heavily inform provider decisions about which treatment course is best for each patient.
In recent years, more HIV drug therapy treatments have become available to HIV patients. Although these drugs are new, they may not represent the most optimal course of treatment. Treating the medical needs of HIV patients with a “one size fits all” approach ignores best practices in care for HIV patients, and clinical evidence indicating varied outcomes for individual patients.
HIV drugs are also not the same as other drug classes. HIV drug treatments, even within the same class, are not necessarily able to be substituted for one another. Many HIV drug regimens do not have a generic equivalent.
HIV & Prior Authorization
Disruptions or delay in treatment can have life-threatening consequences to individuals living with HIV.
This is why HIV-related drugs (including both antiretrovirals and other drugs used to treat co-occurring conditions) must be treated differently than other drugs in coverage formularies.
Cumbersome authorization requirements for HIV treatment can actually lead to more medical complications, higher treatments costs, and worse health outcomes.
Ultimately, this represents a “cost” to the health system in additional medical bills, hospitalizations, and lost productivity of patients.
As an organization of front-line HIV care providers, we support the ability of providers to determine the best course of treatment for their patients.
We also generally support initiatives to improve the health system and cost efficiency of public programs. We appreciate the budgetary impetus behind cost-savings initiatives of where significant savings are involved and patient outcomes are unlikely to be strongly affected. We also respect the burden on state and federal officials to balance budgetary considerations, we believe that the health and well-being of those infected with life-threatening diseases should be exempt from this discussion.
We see a large distinction between HIV medications and other drug classes. HIV medications are life-saving drugs for patients with a life-threatening and communicable disease. These medication should largely be held exempt from general programmatic budgetary discussions.
Certain classes of drugs (in direct proportion to the severity of the conditions they treat and with consideration for the medication’s requirements for effectiousness) should be held as exempt from regular policy changes and political maneuvering.
We believe that the best determination of appropriate medical treatment for HIV patients occurs in the relationship between provider and patient. HIV drug treatment is a highly individualized medical intervention with need for constant provider monitoring and adjustment.
As such, we fully support so-called “Prescriber Prevails” rules that allow the professional opinion of medical care providers to determine the final condition for approval or coverage of a prescribed medication.
Medicare Part D “Protected Classes” Model
We believe the Medicare Part D model of six protected classes of drugs represents a good example of ensuring that life-saving medications are made available to the patients who need them. We support this model for HIV drugs and also for other medications used to treat side effects of these drugs, other infections and co-occurring conditions common with HIV.