A prior authorization or PA program mandates approval by the pharmacy benefit manager, plan administrator or other third-party of a prescribed drug before reimbursement is permitted. The prior authorization is usually initiated by the prescriber or sometimes the dispensing pharmacy initiates the authorization. PAs are required by pharmacy benefit managers for drugs that are high cost ($1000 or more per month), have the potential for abuse, require monitoring to reduce side effects or have shown low efficacy. Continue reading Prior Authorization for Prescription Drugs What You Should Now.

• Why Is the Prior Authorization Process So Complex? The PA process is in many cases muddled by a mix of factors, including:
  • Varying interests, workflows, and motivations of PBMs, patients and prescribers
  • Loads of clinical protocols, each presenting the potential for delays and mistakes
  • Manual reviews of prior authorization requests and medical charts by clinicians
  • Lack of standardization among plan administrators and PBMs
  • Hundreds of health plans and third-party payers

• Not All Prior Authorization Requests Are Reviewed by a Clinician on the PBM Side. Some prior authorization requests submitted electronically are reviewed algorithmically, particularly for simple, lower cost medication. These reviews are often referred to as administrative prior authorization requests. More complex, higher cost medications often require clinician (PharmD) or peer-to-peer reviews at the insurer, however.

• How Can a Prior Authorization Determination Be Overturned? If a PBM denies coverage for a medication requested as part of the prior authorization process, the prescriber has the right to appeal on behalf of their patient. The denial will often be communicated by phone from PBM to prescriber first. A letter from the PBM to the prescriber will then follow. An Explanation of Benefits (EOB) document will typically be sent from the PBM to the patient. The prescriber then follows formal appeals process specific to each PBM. This can be a protracted, multi-step process that requires a material amount of time from providers and insurers alike.

Level One: The first step begins with the doctor and patient contacting the PBM to demonstrate that the requested treatment is medically necessary, and to request that the PBM or health plan re-evaluate the denial.

Level Two: If level one does not resolve the issue, the appeal is then escalated to a medical director at the carrier or an independent review organization (IRO) who has not yet been involved in the adjudication process. The medical director or IRO will evaluate whether the denial was accurately assessed.

Level Three: If the previous steps do not yield a satisfactory result for the provider and patient, the appeal may be taken to a more neutral party for review; often an IRO physician with a similar specialty as the appealing doctor, or an intermediary from the insurance company.

Prior Authorization for Prescription Drugs Conclusion

No one likes going to the pharmacy only to have their prescription delayed by a prior authorization requirement. However, the alternative is far worse. That is everyone being able to go to the pharmacy to get any drug prescribed by their physician without any additional scrutiny. The opioid crisis has proved that when prescribing and dispensation of prescription drugs goes unchecked fraud, waste, and abuse soon follow.