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Multicenter Study
. 2024 Aug 1;142(8):716-721.
doi: 10.1001/jamaophthalmol.2024.2217.

Anti-VEGF Pharmaceutical Prior Authorization in Retina Practices

Sabin Dang  1 , D Wilkin Parke  2 , Guneet S Sodhi  2 , David Eichenbaum  3 , Jared Nielsen  4 , Carl Danzig  5 , Geeta Lalwani  6 , Nader Moinfar  7 , Nikolas London  8 , Alan Kimura  9 , J Michael Jumper  10 , Ken Lord  11 , Veeral Sheth  12 , Dante Pieramici  13 , Anton Orlin  14 , Allison Madson  15 , Monica Horton  15 , Jill Blim  15 , Jessica A Cao  16 , John Thompson  17 , Saira Khanna  1 , Charles C Wykoff  16 , Ankoor R Shah  16
Affiliations
Multicenter Study

Anti-VEGF Pharmaceutical Prior Authorization in Retina Practices

Sabin Dang et al. JAMA Ophthalmol. .

Abstract

Importance: Anti-vascular endothelial growth factor (VEGF) intravitreal injections, a mainstay of treatment for many retinal diseases to optimize visual outcomes, have been included in prior authorization (PA) initiatives. However, if clinicians are extremely accurate in their use of anti-VEGF medications, such administrative burdens may need reconsideration.

Objective: To quantify PA for anti-VEGF medications (aflibercept, ranibizumab, and bevacizumab) that were approved and determine associated administrative burdens experienced by retina practices.

Design, setting, and participants: Prospective multicenter quality improvement study conducted from January 2022 through June 2022, and participants were 9 private retina practices across the US.

Main outcomes and measures: Overall rate of approval of PA requests, reasons for requesting PA, and overall rate of delay of care resulting from PA procedures.

Results: In total, 2365 PA requests were recorded, 2225 of which met inclusion criteria. Overall, 2140 (96.2%) requests were approved. The most common reason for requesting PA, at 64% (1423 of 2225 requests), was reauthorization for a previously utilized medication. Of the 2140 approvals, 59.6% (1277) resulted in a delay in care greater than 24 hours, and 40% (863) were given on the date of service. In a granular analysis of a subset of delayed approvals, 23.9% (173 of 725) were approved within 1 day, 15.9% (115 of 725) were approved within 2 to 3 days, 21.5% (156 of 725) were approved within 4 to 7 days, 26.3% (191 of 725) were approved within 8 to 31 days, and 12.4% (90 of 725) were approved within more than 31 days. Overall, PA denial for step therapy was 2.9% (65 of 2225) of requests and uncovered diagnoses was 0.9% (20 of 2225) of requests. The median staff time spent to obtain a single PA was 100 (range, 0-200) minutes.

Conclusions and relevance: In this study, PA requests were almost always approved but led to a delay in patient care in most patients. The current study suggests that the PA process may not be effective for retina specialists if these results can be generalized to other practices in the US and if less burdensome and less costly approaches could result in similar approval rates. Potential short-term solutions may include eliminating the PA process for bevacizumab and reauthorizations for established patients.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Dang reported receiving personal fees from Genentech and Regeneron outside the submitted work. Dr Eichenbaum reported receiving grants from 4DMT, Aerie/Alcon, Alexion, Allegenesis, Annexon, Aviceda, Bayer, EyeBio, EyePoint, Ionis, Iveric Bio, Gemini, Genentech, Gyroscope, Janssen, Kodiak, Mylan, NGM, Novartis, Ocular Therapeutix, Opthea, ONL, Regeneron, RegenxBio, and Unity; personal fees from Alimera, Apellis, Bausch & Lomb, Bayer, other from Boston Image Reading Center Equity, Coherus, Crinetics, EyePoint, Genentech, Iveric Bio, other from Janssen Stock, Kodiak, Novartis, Ocular Therapeutix, Ocuphire, Opthea, Outlook, Recens Medical, Regeneron, RegenxBio, ReVive, other from ReVive Options, Samsara, outside the submitted work. Dr Nielsen reported clinical trial support from Ocular Therapeutics, Alexion, Bayer, RegenxBio, IvericBio, Genentech, Gyroscope, Kodiak Scientific, and Novo Nordisk; and personal fees from Regeneron (consultant) and Apellis (consultant), and speaker’s bureau fees from IvericBio Steering Committee, Apellis, Genentech Advisory Board outside the submitted work. Dr Danzig reported receiving grants from Alexion, Adverum, Curacle, Bayer, Genentech, Kodiak, Regeneron, IvericBio, Novartis, Roche, Gyroscope, RegenxBio, Unity, Aviceda, Eyepoint, 4DMT, and Rezolute, and personal fees from Adverum, Kodiak, Regeneron, Alimera, DORC, IvericBio, Novartis, Roche, RegenxBio, outside the submitted work. Dr Kimura reported receiving personal fees from Johnson & Johnson (consultant) and RetinAI (consultant) outside the submitted work. Dr Jumper reported being in private practice as a retina specialist, with prior authorizations imposing an administrative and financial burden (implied in the text and does not change the facts presented). Dr Sheth reported receiving grants from Alimera, Genentech, 4DMT, AbbVie, Adverum Biotechnologies, Ashvattha Therapeutics, Aviceda, Chengdu Kanghong, Eyebiotech, Eyepoint Pharmaceuticals, Gyroscope, i-Lumen Scientific, Ionis, Janssen, NGM Biopharmaceuticals, Novartis, Ocular Therapeutix, Ocugen, OcuTerra, Olix, Opthea, Outlook, Oxurion, Perfuse, Recens, Regeneron, Regenxbio, SamChungDang, Santen, Smilebiotek, Unity Biotechnology, and Vanotech, and personal fees from Apellis, Genentech, IvericBio, EyePoint, Kriya Therapeutics, Novartis, Ocuphire, Regeneron, RevOpsis, Unity, Vial, outside the submitted work. Dr Pieramici reported receiving grants from Genentech and Regeneron and personal fees from Genentech and Regeneron outside the submitted work. Dr Orlin reported receiving personal fees from Allergan (ad board) and Regeneron (ad board) during the conduct of the study. Dr Wykoff reported receiving personal fees from 4DMT, AbbVie, Adverum, Aerie, AGTC, Alcon, Alimera, Allergan (now AbbVie), Allgenesis, Alnylam, Annexon, Apellis, Arrowhead, Ascidian, Aviceda, Bausch + Lomb, Bayer, Bionic Vision, Boehringer Ingelheim, Cholgene, Clearside, Curacle, EyeBiotech, EyePoint, Foresite, Frontera, Genentech, Gyroscope, IACTA, InGel, IVERIC Bio, Janssen, Kato, Kiora, Kodiak, Kriya, Merck, Merit, Nanoscope, Neurotech, NGM, Notal Vision, Novartis, OccuRx, Ocular Therapeutix, Ocuphire, Ocuterra, OliX, ONL, Opthea, Oxular, Palatin, Perceive Bio, Perfuse, PolyPhotonix, Ray, RecensMedical, Regeneron, RegenXBio, Resonance, Roche, Sandoz, Sanofi, SciNeuro, Stealth, Surrozen, Suzhou Raymon, Sylentis, THEA, Therini, TissueGen, Valo, Verana, Visgenx (consulting fees), and grants from 4DMT, Adverum, AffaMed, Alexion, Alimera, Alkahest, Allgenesis, Amgen, Annexin, Annexon, Apellis, Asclepix, Bayer, Boehringer Ingelheim, Chengdu Kanghong, Chengdu Origen, Clearside, Cleveland Clinic Foundation, Curacle, EyeBiotech, EyePoint, Gemini, Genentech, GlaxoSmithKline, Graybug, Gyroscope, IONIS, iRENIX, IVERIC bio, Janssen, Kodiak, LMRI, McMaster University, Nanoscope, Neurotech, NGM, Novartis, Ocugen, Ocular Therapeutix, Ocuphire, OcuTerra, OliX, Ophthotech, Opthea, Oxurion, Oxular, Oyster Point, Perceive Bio, Pykus, RecensMedical, Regeneron, RegenXBio, Rezolute, Roche, SamChunDang Pharm, Sandoz, Senju, Shanghai Henlius, Skyline, UNITY, Valo, Verily, and Xbrane (grants for research support as PI), and stock options from InGel, ONL, Panther, PolyPhotonix, RecensMedical, TissueGen, Visgenx, and Vitranu outside the submitted work. Dr Shah reported receiving personal fees from Notal Vision, Regeneron, RegenexBio, and being a shareholder of Apellis outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Time in Delay to Authorization Stratified by Number of Days
Figure 2.
Figure 2.. Estimated Staff Time Required to Obtain Prior Authorization Stratified by Number of Minutes
See this image and copyright information in PMC

References

    1. Glasser DB, Parikh R, Lum F, Williams GA. Intravitreal anti-vascular endothelial growth factor cost savings achievable with increased bevacizumab reimbursement and use. Ophthalmology. 2020;127(12):1688-1692. doi: 10.1016/j.ophtha.2020.06.012 - DOI - PubMed
    1. Patel S. Medicare spending on anti-vascular endothelial growth factor medications. Ophthalmol Retina. 2018;2(8):785-791. doi: 10.1016/j.oret.2017.12.006 - DOI - PubMed
    1. Centers for Medicare & Medicaid Services Data . 2022 Medicare Part B Spending by Drug. Accessed November 9, 2022. https://data.cms.gov/summary-statistics-on-use-and-payments/medicare-med...
    1. Resneck JS Jr. Refocusing medication prior authorization on its intended purpose. JAMA. 2020;323(8):703-704. doi: 10.1001/jama.2019.21428 - DOI - PubMed
    1. Hodgson N, Wu F, Zhu J, et al. Economic and quality of life benefits of anti-VEGF therapy. Mol Pharm. 2016;13(9):2877-2880. doi: 10.1021/acs.molpharmaceut.5b00775 - DOI - PubMed

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