Physician Burden and Time Delays in Initiating Immunomodulatory Therapy for Noninfectious Uveitis and Inflammatory Eye Diseases.

Abstract

To assess the additional time and effort required and resultant delays imposed by insurance-mandated prior authorization for medications treating uveitis and ocular inflammatory disease. Retrospective cohort study. Patients with uveitis and ocular inflammatory disease at the University of Texas Southwestern Medical Center requiring approval for new systemic immunomodulatory therapy between February 2023 and January 2024. Infusion-related medications were excluded. Electronic medical records were reviewed to assess prior authorization requests, appeals, and related data for initiating therapy. Success rate of obtaining requested medications, time to initiation, additional steps required (eg, appeals, peer-to-peer consultations), factors influencing approval (eg, insurance subtype, medication class), and reliance on patient assistance programs. A total of 83 patients had 107 requests for new immunomodulatory therapy. Uveitis subtypes included pemphigoid (38%), anterior uveitis (13%), intermediate uveitis (8%), posterior uveitis (1%), panuveitis (35%), and scleritis (5%). Medications included methotrexate (20.6%), mycophenolate mofetil (12.1%), adalimumab (34.6%), tocilizumab (1.9%), baricitinib (16.8%), and tofacitinib (9.3%), with 75% considered "off-label." Approval rates were 100% for on-label and 52.3% for off-label medications (P = .033). Off-label requests were twice as likely to be denied, requiring more appeals (1.07 vs 0.50; P = .01). Average time to initiation was 28 days for on-label and 41 days for off-label medications (P = .01). Private insurance had higher approval rates than Medicare for off-label requests (59.5% vs 36.4%; P = .05). Patient assistance programs were required in 63% of cases. Prior authorization creates significant administrative burdens and delays, disproportionately affecting off-label therapies and delaying critical vision-preserving treatments.