Best Practices for the Management of Neuroendocrine Tumors - Episode 15

Practice Pearl 3 Challenges in Obtaining Authorization for the Treatments for NETs

April 2, 2021

Megan May, PharmD, BCOP, reviews the authorization process for treatment options for the management of NETs.

Daneng Li, MD: Megan, have you encountered any potential challenges in terms of obtaining authorization for treatment for these patients, such as with any of the somatostatin analogues or with any treatment in general?

Megan May, PharmD, BCOP: With these agents, there are 2 types of authorizations to talk about. One is if the patient is getting the agent in our infusion center, getting those prior authorizations through the insurance. If we are sending a prescription home with the patient, like how Cecilia [Lau] was talking about using the injections at home and doing self-administration, then that is a different type of prior authorization that we are involved in.

If we are giving the agent at our institution [Baptist Health Lexington], we require insurance authorization prior to giving the medication. So up front, it is important to tell the patients that these are higher-costing medications and that it takes awhile for the insurance to approve the medication, and [to tell them] not to expect that, if the provider recommends it today, then they will get the medication today. For us, it usually takes at least 48 hours to get that approval before we can administer the medication. For the agents that we are sending home with the patient, that is going through their prescription insurance, so that is a different process of getting that prior authorization. I know that here, our pharmacy is involved in helping fill those forms out to get the authorization. Once a patient has authorization and we get the co-pay amount if they can afford it, then they can get the medication shipped to their house.

Another issue, though, is looking at funding. Is their co-pay too high after the insurance has approved it, or were we not able to get that prior approval through the insurance? Fortunately, there are a couple of options for our patients. A challenge that we have is the affordability, but there are some patient medication-assistant-support programs for these agents, which we are fortunate to have. There are 3 main types that we deal with. We have the manufacturer-provided patient assistance programs, or PAPs. We can also do medication funding through different charitable organizations where we can obtain foundation money for our patients. Some health care systems have charitable care funding. I know that here, we have a foundation that can help some patients afford their medications if there is a financial toxicity for them.

Depending on the patient’s eligibility, which would depend on which insurance they have and their annual income, patients can receive different medication access support programs through 1 of these avenues. For us, the important thing is getting the medication to the patient, so we will jump through all the hoops we have to in order to make that happen for them.

Daneng Li, MD: As a provider, I thank all my pharmacy colleagues. That is so helpful to me in terms of helping me understand and navigate through this complex process to make sure our patients get the care that I want them to get to provide the best treatment for them.