Effective Prior Authorization Management
The effective management of the Prior Authorization (PA) function is a crucial aspect of healthcare that ensures patients receive the appropriate medications while controlling costs. Pharmacy Benefit Managers (PBMs) play a vital role in this process. Inappropriate managing of the PA process can negatively impact patient outcomes, and result in much higher pharmacy and/or medical costs.
ENSURING PATIENT SAFETY:
The most important function of the PA process is to ensure the safety and appropriateness of prescribed medications, guarding against adverse drug interactions and potential harm. PBM’s must carefully assess the medical necessity and appropriateness of the prescribed therapies.
A secondary purpose of the PA process is to evaluate the clinical and cost effectiveness of the prescribed therapy. By identifying and requiring the use of lower cost, first line therapies whenever it is clinically appropriate, PBMs can save expenses for their clients.
COLLABORATION FOR EFFECTIVE HEALTHCARE:
PBMs serve as intermediaries between healthcare providers, patients, and payers. Through efficient PA management, they foster collaboration and coordination among these stakeholders. PBMs facilitate communication, provide necessary information, and ensure better alignment between healthcare providers and payers. This collaborative approach results in a more streamlined and patient-centered healthcare system.
Ineffective PA management can result in unwanted outcomes and excessive cost. Rebates create a perverse incentive for PBMs which encourage the approval of medications that may not be the best course of treatment for the patient. PBMs report overall PA approval rates that range from 40-90%. Such a wide range indicates that different PBMs exercise different strategies for managing their PA processes.
When a PBM authorizes a high-cost drug, and the member becomes stabilized on that drug, there is very little chance of convincing either the member or their doctor to try a lower cost therapy in its place. Therefore, ineffective PA protocols result in higher plan costs not just for the current period, but for years to come.
CCRx closely monitors PA protocols and helps our clients identify the PBMs that we believe do the most effective job of managing the Prior Authorization process. Doing so not only ensures better outcomes for patients, but it saves money for the payers, as well. We continually monitor these programs and work with the PBMs to understand any decisions that seem unusual. This is not a process that can be ignored- it requires ongoing attention of clinical experts.
CCRx is a pharmacy consulting firm dedicated to achieving the best possible outcomes for patients at the lowest possible cost. We are aligned with the interests of our clients, and never take payments from PBMs for placing business with them.
Conflict of Interest July 2023 Recently a respected competitor published an article condemning most pharmacy benefit consultants for not disclosing conflicts of interest. They correctly pointed out that many big corporations such as “Boeing and UPS to local school...
New Transparency Models May 23, 2023 Both Express Scripts and OptumRx have announced new, optional Pass-Through pricing programs. Their clients can adopt this new pricing strategy, or they can continue with non-transparent pricing where the PBM won’t disclose the true...
Invokana Pricing slashed via The Mark Cuban Cost Plus Drug Company April 2023 The Mark Cuban Cost Plus Drug Company has announced that they have entered into a contract with JanssenUS, a subsidiary of Johnson and Johnson, to distribute Invokana, an important...
Novo Nordisk and Sanofi to cut Insulin prices, following moves by Eli Lilly March 2023Novo Nordisk to cut U.S. list prices for several insulin products by up to 75% next year. Sanofi announced that it will cut prices by 78%. Effective January 1st, 2024. Generally...
Senators introduced bills to reform PBMs and create new FTC probe February 2023 U.S. Senator Cantwell (D-Wash) recently re-introduced the Pharmacy Benefit Manager Transparency Act of 2022 which was previously co-sponsored by herself and Senator Grassley (R-Iowa). The...