Prescription Medication Prior Authorization Explained
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- Опубликовано: 26 сен 2024
- Insurance Companies and Pharmacy Benefits Managers (PBMs) Require Prior Authorization for Certain Prescription Medications in Order for Them to Be Covered.
Prescribers (i.e. Doctors, Nurse Practitioners, Physicians Assistants, etc.) must first determine if a medication requires prior authorization.
Next the prescriber must submit the prior authorization either via Fax or Electronic Submission.
Then the prior authorization tech at the PBM may need to enter the information from the fax into their own computer system.
A prior authorization pharmacist then reviews the request.
If the request is approved, the medication can be filled at the pharmacy.
If the request is denied, the rationale for the denial is sent back to the prescriber.
The prescriber can then provide additional clinical information or the request can be escalated to a medical director at the PBM.
Prior Authorizations generally take 1-3 business days and many physicians say that the delay in patient care results in adverse events and even unnecessary hospitalizations.
Correction: 25% of surveyed doctors said prior authorization resulted in an adverse health event and 16% said that delayed patient care resulted in hospitalizations.
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I love all of your videos as they are very detailed and informative. I also hate your videos because they show how corrupt and evil our health care system has become. I used to like treating patients, but now i wish i would have become an elecrical engineer and worked for Lockheed Martin
I also love and hate my videos. Thank you for watching.
Omg your voice and energy is impeccable!!!! I learned so much!!!! Please keep going and helping make the Pharmacy Industry great by keeping us newbies educated!!!! KEEP REACHING FOR OUTTER SPACE!!!!!
Thank you for watching and for your support.
I am a pharmacist. This video presentation is excellent! Thank you.
Thank you for watching.
I hate this process. I have an adult son that takes Vyvanse and Adderall as well as several other psych meds. My son is mentally challenged as well as autistic..and has bipolar. When it came time to fill his Vyvanse they denied the refill and said they needed prior authorization. Called the doc....the doc did her part...but we had to keep calling doct n pharmacy. He was without his meds for over 3 weeks. It's dangerous to abruptly stop these types of medication!! And they have nothing to say but...sorry we are backed up from january...it may take a few weeks or a month. I was so upset. My son's behaviors were out of control..having meltdowns n anger..this is a horrible process and it's dangerous to not make sure that people get their medication on time
Agreed. I’m sorry sorry to hear what happened.
Agreed but also this is common with Medicaid payers. There have also been some shortages of ADD/ADHD medications in the market place and some health plans have not been proactive in addressing it. The one I work for removed our PA requirements and MAC (often referred to as member pay the difference) penalties for people forced to get brand name Adderall XR because the generic was unavailable. Once the generic was readily available those PA and MAC penalties went back into place. One thing I wish more health plans and PBMs would do is stop authorizing drugs that they know good and well the patient will be on for their lifetime for one year periods. That just is frustrating and makes more work for everyone, including the health plan PA staff. The simple solution is once the PA has been approved approved it indefinitely so patients do not have to keep jumping through the PA hoop for a medication that is critical that they take or critical that they do not stop suddenly without following appropriate tapering. I know this may be too late to be of help now but see what your states prior authorization turnaround time requirement is if there is any. Most states seem to have them. usually 48-72 hours for non-urgent requests. If they are exceeding that turnaround time look into filing complaints with your state insurance commission because anything more than 72 hours is just absurd. I have been a PA technician at multiple PBMs since 2011 and that would never have flown at any of the companies I worked for. If you son is covered by Medicare or Medicaid I can guarentee that there are strict turnaround times and consequences for not meeting them.
I just got my Vyvanse hit with one of these and got a temp 30 day supply of this. It is the only one in my area that the drug shortage isn't effecting. My insurance has an electronic form that will send a fax to my psych APRN and hopefully this gets sorted out. My regular doctor feels better giving me this between psych providers vs Adderall or Dexedrine. I switched to a different plan which doesn't have this requirement but I have to pay $120 more for the premium. It took them 12 days to send the letter to me too.
If there was a delay in the Prior Authorization being completed, I can guarantee it was not by the Insurance company or PBM - it was the doctor's office that was backed up. I've worked on both sides... I know Medicare & Medicaid plans have to follow CMS (Centers for Medicare and Medicaid Services) guidelines which are very strict so that PAs need to be processed within 72 hrs for a standard request or within 24 hrs for an urgent request.
It may be a little easier if you try different drugs BEFORE getting Vyvanse to prove that the dr is trying something less strong, etc. it’s ridiculous!! It will be approved most likely if you skip through that hoop for ‘em. 😢
I cant ask faceless corporate investors to pay for an extra levaquin tablet just cause some urologist and I arbitrarily decided that my febrile prostatitis might resolve a little faster. You're so genuinely incredulous that it's endearing.
Thank you for your comment.
Great video. I am a pharmacy tech that has working the prior authorization departments of multiple PBMs/health insurance companies for the last 10 years. One thing I will point out is every PBM/health plan is difference. I have worked for some that it felt like they intentionally threw up road blocks to avoid spending money. I have also worked for some, such as the one I work for now, where the clinical staff actually makes their decisions based on what they feel is best for the patient and not the bottom line. I have been on both sides of the prior authorization process. Aside from working for PBMs as a PA tech I have also worked for a major medical group in my state and worked with a group of pharmacy technicians that submitted PA requests for about 450 primary care providers. Some PBMs are a nightmare to deal with. Some are very easy. The health plan I work for now actually runs their PA department different from most PBMs. The pharmacy technicans actually do all the case set ups and documentation such pulling in the PA criteria and the relelvant information from the chart notes and if the information we needed was missing we reached out to the office to try and get it. With the exception of CAR-T medications the pharmacy technicians would actually summarize the request and make a recommendation to approve or deny and then move it on the PA pharmacist who would review the information and either agree with the recommendation and send the case back to closed as approved or denied or they would override the recommondation with their clinical judgement and send it back to be completed. Some PA drugs had protocols such as simple step therapy where if all the required alternatives had been tried and failed or the PA policy was just confirmation that the drug is being used for a specific diagnosis the pharmacy technician could approve it on the spot and get it out the door as it did not require clinical judgement. Letter templates are used for consistency, however, on denials, we always tailored the language to the specific situation as much as possible. Word of advice to people in positions submitting PAs. The most common cause for delay is submitting a request with no supporting documentation or on the flip sending us hundreds of pages of chart notes that are entirely unnecessary. If you send us 150 pages of chart notes we have to review them all to ensure that there is no other PA request within that fax. Due dilligence. That takes time. I cannot count how many times I have had angry doctors send me 300 pages of chart notes for a simple step-therapy PA and everything I needed to approve was on the PA form but because they sent the patient's entire medical history I now have to review every page to make sure that more than one PA request was not submitted together. You would also be surprised how often that happens. The ultimate score for a doctors office or medical practice is a pharmacy technician that has experience in the PBM world but my experience has been not a lot of medical offices feel the need to have an on staff pharmacy technican to handle PA requests for them. I used to love doing that because I was able to get the vast majority of my PA requests approved or intervene and have the prescribing provider change the drug if I knew there was no way it was gonig to get approved. Medical offices shouldn't need to do this but this is the reality of the American health care system today.
Super information. Thank you!
Maybe you can tell me why my insurance company doesn’t want to pay for my medication
We should not accept this as justified. Bad for patients and physicians
Whatever you kneed to tell yourself.
Thank you thank you thank you for putting this together. I’ve learned more about the PA process from your video than years of trying to reverse engineer it from the outside.
Super! Thank you for watching.
Thanks! I’ve been looking for something like this. There are a lot of videos about prior authorization for surgery etc but people are a lot more likely to run into prior authorization for prescriptions than surgery and other procedures.
Thank you for watching and for your comment.
You can explain this in one minute and the visuals tell a story. a) inundate the prescriber with paperwork in hopes the consumer just pays OOP. b) Repeat (a). SO, CVS uses CVS (PBM). Isn't this a conflict of interests? Instead of using this Rx Insurance, I just pay 10X less at the Wal-Mart Pharmacy.
Thank you for your comment.
Good GOD.
What have we become.
AI telling us what we need.
Thank you for sharing your thoughts.
Great information! Thank you!
Thank you for watching and for your feedback.
What is prior authorisation? Surely if a prescriber prescribes a medication they have authorised it and the patient should bebable to puck it up from the pharmacy?
Sorry if this sounds naive. I live in the UK.....
The intent by insurance companies is to reduce cost for patients by providing clinical oversight to determine whether those prescriptions are actually needed.
What actually ends up happening is that this is another tool for insurance companies to reduce cost for themselves.
awesome video. are there any automated systems that try to make this process easier from the physician standpoint?
Yes, but not widely adopted or successful. It’s referred to as ePA… for Electronic Prior Authorization.
I see. do you know why they aren't super successful? it seems like a good problem for software/AI @@ahealthcarez
Great job. Thank you.
Thank you for watching and for your feedback.
Hi Dr. Bricker, what defines the doctor specialty, is it the primary specialty attached to a provider's NPI?
Yes
Hi Dr Eric, I am curious to know more about loopholes in PA system. As patient myself who required a PA for my medication I had to struggle last year to get my medication and it took almost 2-3 weeks to get the issue resolved. Are you saying no PBM has created an automated solution to reduce the time to get PA approval or denial Response.
Correct. Intentionally slow.
I have been in the PA world for a decade. There is a lot about it that cannot easily be automated. In some cases, PAs that are simple policies like matching a diagnosis or step therapy (try drugs A and B before we will approve Drug C) can be automated and many PBM actually have automated those through CoverMyMeds and various webportals that can be built as modules into various electronic medical record systmes used by clinics and hospitals. That being said, drugs to treat complex conditions like cancer, autoimmine disorders, genetic disorders, etc often have complex PA policies that require the judgement of a clinical person like a pharmacist or doctor so they are still highly manual. As someone that has spent a decade in both the PBM field and the medical office field processing PA and submitting PAs I can assure you not all of the delays are the PBMs being intentionally slow. On the contrary, most states dictate how long health plans have to make a determination and it usually not more than 72 hours. A huge source of break down is communication between the pharmacy and the provider office and the provider office and the insurance plan. I also spent nearly a decade in a retail pharmacy and trust me, every single day someone at a doctor's office would tell me they never got any of the refill requests we had been faxing for the last week. Without fail. Works both ways though because there were many times an provider said they faxed something and we never got it. There are also many times a provider's office says they faxed the PA and didn't and are blaming the insurance company to cover their own behinds. There are also times they legitimately faxed the request in and for whatever reason it never materialized on the PBM side. Don't know how or why this happens but it happens. Delays are also often a result of the office sending the PA to the wrong health plan, the wrong fax number to the correct health plan (and internal breakdowns at the health plan resulting in the fax never making it to the intended recipient), or the office getting the PA to the right health plan at the right fax number but the PA request was incomplete. This happens ALL. THE. TIME. We get a PA request with a PA form and nothing else. Sometimes that is sufficient, most of the times it isn't. The more expensive the drug and the more complex the medical condition is the more likely it is we will need supporting documentation. Think about like this. If they are asking us to pay for a drug that is $120,000 a year (Stelara) then a barely filled out PA form isn't going to be enough. We need chart notes to document the diagnosis the drug is being used to treat, the severity of the diagnosis, any prior treatments tried and failed, lab work, etc. When that is not sent with the PA form we either have to deny the request or put it on hold to request additional information. Most states require a good faith attempt to get said information prior to denial so it then becomes incumbent on the provider to respond in a timely fashion. When we fax a letter to their office and say we need to know this information by xx date or we will render a decision based on the information provided (aka deny) if the provider's office never responds or responds a month later that is not on the PBM at that point. This is a two-way street. The health plans and PBMs have to be transparent simplify the process to submit a PA. The prescribing providers have to take ownership of making sure once it has been identified the medication the prescribed needs a PA to ensure it is submitted with supporting documentation AND to respond to requests for that information in a timly fashion as well. It's not fair to blame the insurance companies soley for delay nor is it fair to blame providers and their office staff either. Unfortunately balls get dropped on every side of the equation and the patients are the ones that suffer in the end.
Some insurances do have some meds that get "auto -approved" on Cover My Meds simply with confirmation of the specific diagnosis that the medication is FDA approved for. And Yes, I can say that with 100% certainty.
If the prescriptions that CVS or other larger pharmacies require PA for vary, what is the determining factor? And do small mom-and-pop-style pharmacies determine which prescriptions require PA using the same criteria?
Great question. It’s not the pharmacy side of CVS… it is their PBM that they run. Pharmacies do not determine if a med needs prior authorization. The PBM does.
Thank you for watching.
The determining factor is the insurance formulary. You can generally find your insurance plan's drug formulary on their website. Some plans will actually provide what the coverage criteria is as well. There is also a difference between a standard prior authorization and a "Non-formulary exception". A med can be a preferred drug that is included on the insurance formulary but that requires authorization for coverage - usually to confirm the med is being used for an FDA approved diagnosis/treatment and possibly that the patient also doesn't have "exclusion" criteria which generally is a safe guard to confirm the prescriber isn't giving you a med that can produce severe adverse reactions (like including higher risk of death or complications) because of other conditions or medications you take. A "Non-formulary Exception" is when a drug is NOT on the plan's formulary, so it requires FDA approved diagnosis/treatment, etc and ALSO the patient has either tried & failed on or has a contraindication to one or more covered formulary alternatives.
@@wendytrue6800you nailed that sis!
I need more information about prior authorization process for prescriptions and for part A billing
So manny people play doctors to care for patients. How does the person approves the request do clinical decisions without full knowledge of the patient’s condition and medical history? Does the subscriber send in the whole medical record?
Good question. Just certain parts of the medical record.
I have a question... I've been waiting for my medication to be authorized for 1 week now. My husband says just pay for it and have the insurance company reimburse. Is that possible?
Would have to ask pharmacy if they will submit claim if drug approved after you have already paid them.
I work for a health insurance company the answer is yes and no. If you pay out of pocket and no PA has been done or has been denied than the health plan is very likely to tell you tough luck you are out the money. If you pay out of pocket and the PA gets approved, as long as it is approved retroactive from the date you paid cash for the drug they will most likely reimburse you. If it has been more than 10-14 days between when you paid cash at the pharmacy and when the PA was approved you will have to submit a paper claim with receipts and the insurance comany will mail you check for the difference betwene what you paid and what your copay/coinsurance would have been because pharmacies often contractually have a small window of time to resubmit cash pay claims back to the insurance company and that window typically closes around 10-14 days. Paying cash while waiting for a PA is risky, especially if the drug is expensive. In the 18 years I have worked as a pharmac tech in retail pharmacy and PBMs I have seen people do this and then have the PA get denied or the Doc decide not to do it and change drugs and the patient ends up stuck with the bill.
Agree with above, with additional comment. In my experience some insurances especially state medicaid will NOT backdated PAs. You can call your plan's customer service line and ask what their policy is though. Other plan's will back date at either the prescriber's or patient's request, once approved.
This changed for me this year. The same items I got for my son and I last year with no problem I ant get at all. And it’s a circus
Agreed. Thank you for watching.
Hi Dr. Bricker. As far as specialist criteria, you used the hypothetical scenario for retinol but what would you think of that criteria for an anti-cancer or other specialty drug where inappropriate use could result in patient harm in addition to wasted healthcare dollars?
Tough because of access problems for people in rural areas without specialists nearby. Many times the PCP will call the cancer doc for advice on a mutual patient, but the patient is on the PCPs office, not the oncologist.
Onc may recommend drug, but PCP prescribed it since in PCP’s office.
Also, interns/residents write most of the prescriptions for attending specialists at the attending’s direction. Med needs to be filled even though not a specialist writing the script.
@@ahealthcarez In my experience the phrasing is closer to “prescribed by or in consultation with”. Agree with the broader points of your video and thanks for the reply.
@@rickh1755 The health plan I work uses this language. If the requesting provider for a drug like Remicade was a family practice doctor we would approve it (if all the other PA criteria had been met) if there is documentation that they are seeing the appropriate specialist or at least that the prescribing provider has consulted with the appropriate specialist and they concur with the treatment. Sometimes our pharmacists would waive that criteria if they felt the intent of the policy had been met and delaying access to the drug could worsen the patient's condition. Our pharmacists were usually pretty hesitant to deny simply because the requesting provider was not the appropriate specialty because the vast majority of times those denial got overturned on appeal any how which costs not only the health plan more money but the employer groups more money as well on top of wasting time and delaying care.
MY HUSBAND is in severe pain he has been on the same dosage for 1o years he goes through 14 days priorauthorization back to back his doctor is about to cut him off after 10 years because of the insurance company. the stress increases his pain and his emergency supply that he has to pay cash for is about to run out he will have to go into dangerous withdrawals and i will have to take him to the hospital .all because the authorization is taking forever . this harms pateents and doctors.
I’m sorry. Thank you for sharing your story.
I got a prior authorization for a prescription for a lavalier microphone, and it was accepted! Woo hoo!
🤣🤣 I’m using a shotgun mic now. Thought it would be better. 🤷♂️
@@ahealthcarez Oh yeah, it's so much better now! So good that my office coworkers are now talking about how much they hate insurance companies 😀
Great video Dr bricker. What’s the qualifying criteria for a drug to be a PA warranted to drug? Is it solely high priced Rx? I lived in an area highly affected by the opiate epidemic and heard horror stories of addicts being on life saving anti opiate medications that are denied for this causing them to go back to street drugs.
Great question. Discretion/Internal Policy of the PBM. The consequences are real.
Thank you for watching.
What if I don’t have insurance
Then no prior authorization. Just pay cash.
Can I just switch to Walgreens and avoid this?
Unfortunately no.
It's not the pharmacy it's the insurance plan requirement. He was only using CVS as an example
In other words, these Bean Counters know more about what my Doctor does about my health and what Rx I need or not. I have CVS Rx and it it's just cheaper and less hassle to just pay 10X less out of pocket at a Wal-Mart Pharmacy.
Thank you for sharing your thoughts.
If the prescription medication needs a more thorough review by a licensed professional then a pharmacist (your "bean counter") is the best person for the job. Nowadays they graduate with a Doctorate in medicines - so that makes them a Prescription drug specialist. I'd trust a pharmacists opinion over a doctors opinion on medications - that's their specialty. They know more about how the drugs work, what they interact with and what side effects they potentially have than the doctor will ever know.
@@wendytrue6800 We'll, 80% of the US drugs you can get OTC in most other countries dispensed by clerks, and they don't have the overdose or wrong prescription errors as the US does. I researched this to include the only two countries in the World that allow TV ads, are New Zealand and the USA.
And Pharmacy Techs fill most of the Rx. Perhaps the reason drugs are so high in the US is because were paying someone 6 figures that most folks who can follow directions can do. With the exception of compounding a drug, it's not rocket science.
Thanks
That's ridiculous, a general practitioner has the clinical knowledge to order retinol.
#Agreed.
the system is rigged against the patient in so many ways its mind boggling
True. Thank you for watching.
OK... CVS
A podiatrist is a doctor.
Thank you for watching and for your feedback.
As a prior authorization specialist, some of this can be mitigated by knowing the guidelines for the insurance providers and submitting the appropriate documentation, correct coding, and staying within any guidelines related to age, labs, body metrics, etc. during the first submission to reduce denials.
Thank you for sharing your thoughts.
I feel these are cumbersome by design to extract rebates from drug manufacturers (in exchange for relaxing PA requirements along with favorable formulary positioning)
May be. Thank you for watching and for your input.
You are exactly correct. Insurance doesn't want to pay for anything if they dont have to. Thats why I try to offer a discount card if its available