An oncologist advocacy group wants Congress to set a 72-hour deadline for pharmacies to fill cancer drugs for patients, the latest on a growing list of calls for prior authorization reform.
The Community Oncology Alliance (COA), which represents independent oncologists, is in talks with lawmakers on both sides of the aisle to put out the legislation. The effort is in response to the growing influence that pharmacy benefit managers (PBMs) have over how prescriptions are filled.
“What happens is the PBM will in many cases dictate their corporate brother or sister specialty pharmacy fill the prescription,” said COA Executive Director Ted Okon in a briefing with reporters Tuesday. “We see more delays and denials.”
The legislation would specify that after the 72 hours are up, a patient can get the prescription filled at any pharmacy they want or at the oncologist’s practice. The patient would still pay the in-network rate. Oncology practices can have their own associated retail pharmacy or a physician dispensing facility. State regulations dictate what type of arrangement an oncology practice can have, Okon said.
So far, the legislation hasn’t been introduced, but Okon hopes to get it included as part of a package of health program extenders that Congress must fund before current funding expires May 22.
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The Pharmaceutical Care Management Association, which represents PBMs, said that formulary management tools such as step therapy and prior authorization are vital to keeping treatments affordable.
"Health plan sponsors include tools like step therapy and prior authorization in their pharmacy benefits in order to reduce inappropriate drug use, lower costs, and improve quality," the group said.
This potential bill isn’t the only effort in Congress to tackle prior authorization, an area of major criticism from providers.
A bipartisan bill led by Rep. Suzan DelBene, D-Washington, introduced last year aimed to streamline and standardize the approval method for prior authorization in Medicare Advantage plans. A major issue is that each plan has its own unique way of implementing prior authorization, according to a release on the bill introduced last June.
Physicians have been criticizing the burden they face meeting prior authorization requests, which are on the rise. A recent survey found 84% of providers say the number of medical services that require a prior authorization request has increased.
The cost for a prior authorization requirement for a doctor practice also increased by up to 60% in 2019 to manually put together a request.
The time range for a prior authorization request to be granted can take anywhere from a couple of days to weeks, Michael Diaz, an oncologist from Florida, told reporters at the briefing. But cancer treatments require faster approval and dispensing of drugs because of how quickly a patient’s condition can change.
“Cancer is unique in that it can evolve quickly and rapidly sometimes,” Diaz said.
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Insurers also pushed back on the criticisms of prior authorization.
While it didn’t comment on the prospective legislation, insurance lobby group America’s Health Insurance Plans (AHIP) said prior authorization is an important tool to manage rising drug costs.
“Only used in very limited circumstances, prior authorization protects patients and prevents the overuse, misuse or unnecessary (or potentially harmful) care,” AHIP said in a statement to FierceHealthcare.
AHIP has launched a new initiative aimed at streamlining and approving prior authorization requests from doctors.