Shari N. Allen, PharmD, BCPP
Philadelphia College of Osteopathic Medicine-School of Pharmacy
CPNP Student Committee Member
The World Health Organization defines adherence to long-term therapy as “the extent to which a person’s behaviour – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.” Non-adherence to therapy is a frequent occurrence in patients diagnosed with a mental illness. Non-adherence to medications, particularly psychotropic medications, may lead to adverse outcomes such as exacerbation of illness, poor self care, and hospital readmission. There are many barriers to medication adherence, one being the inability to obtain prescribed medications after an inpatient hospital discharge which may be secondary to the cost of the medication and/or the need for a prior authorization. A prior authorization is a requirement implemented by managed care organizations intended to allow members to receive medications that are both safe and effective for their diagnosis but also cost effective. In some cases when patients are being discharged from an inpatient hospital admission, the medication reconciliation process may not routinely consider a patient’s ability to obtain or afford the medication. This is an opportunity for pharmacists and pharmacy students to aid in patient care.
Introducing prior authorization determination into the scope of pharmacist duties may help to improve patient care. At a 54 bed acute care psychiatric hospital a pharmacist initiated prior authorization process was implemented. After appropriate training on how to determine the prior authorization needs of a patient’s medications and how to complete the prior authorization process, pharmacy students on their Advanced Pharmacy Practice Experience (APPE) Psychiatric Elective were utilized to help run the service.
Prior to a patient’s discharge the pharmacist and pharmacy students reviewed all of the patient’s psychotropic medications. Each medication was checked against the patient’s primary insurance plan to determine if a prior authorization would be needed or if the co-pay for the prescribed medication would be affordable to the patient. If the co-pay was not affordable for the patient, alternative options were suggested to the treating psychiatrist. When a prior authorization was needed for a patient, the appropriate forms were filled out and a letter of medical necessity, written by the pharmacist/pharmacy student, accompanied each form. The letter of medical necessity covered patient specific reasons why the prescribed medication may be preferred over formulary options. The letter covered medical comorbidities (i.e., diabetes, obesity), social history (i.e., substance abuse), and patient history (i.e., non-adherence, previous treatment trials and failures) and how each of these factors may warrant a non-formulary option over a preferred formulary option. The prior authorization form and letter were faxed to the insurance company. After the determination by the insurance company was made, this information was then communicated to the treating psychiatrist. In the event of a denial, the pharmacist and pharmacy students were able to help determine alternative options including another medication, patient assistance programs, coupons or vouchers. Through this service, 460 prior authorizations were initiated between 2013 and 2016, with an approval rate of approximately 91%.
Allowing students to help with this process gives the pharmacy student the opportunity to review medication classes, search the literature to determine equivalent doses or appropriate alternatives, compare and contrast the risk and benefits of various psychotropic medications, apply didactic knowledge to a patient case, improve verbal and written communication skills, and learn to integrate themselves into the health care team. By implementing this program and facilitating prior to a patient’s discharge, the pharmacist and pharmacy students can help aid in patient care and improve at least one barrier to patient adherence while serving as a learning process for the pharmacy students. This serves as a win-win for both the patients and students.