In our current world of healthcare, patients encounter various roadblocks when filling their prescriptions at the pharmacy. More recently, patients may have started hearing the words “prior authorization” more and more from their pharmacist. What does this mean? A prior authorization (PA) occurs when the Pharmacy Benefit Manager (PBM) requires the prescribing healthcare provider to submit additional paperwork (which may include medical records) to meet a certain clinical threshold.
Historically, PAs were utilized for two reasons: first, that they were instituted on high cost medications that had cheaper alternatives to ensure patients tried less expensive alternatives. Second, they ensured that medications were medically necessary and being used to treat the indicated disease or medical condition.
According to the American Medical Association’s (AMA) recent survey taken in December 2020 and published earlier this year, 94% of surveyed physicians found that PAs delay access to necessary care. What’s even more shocking is that commonly prescribed generic medications have had PAs instituted.
Chief Medical Officer of Scripa Insights, Dr. Paul Bradley, recently had a PA come across his desk for Hydroxyzine 50 mg from a major insurance carrier. Hydroxyzine is an antihistamine used to treat anxiety and can cost as low as $7 at the pharmacy. The notice failed to offer an alternative and simply recommended that Dr. Bradley prescribe another medication on the formulary!
The AMA also reported that close to 79% of the time, PAs can lead to patients abandoning their recommended course of treatment and 30% of surveyed physicians have reported that PAs have led to a serious adverse event for patient care.
As this case has demonstrated, more drugs and treatments are being flagged by PBMs for PAs, and it’s not just the expensive brand and speciality medications. There has to be a better way to simplify the PA process so patients are able to access their life-saving medications in a timely manner.
Scripta works with our clients on multiple different levels. We assist and recommend an optimized plan design that benefits the plan sponsor, and our team of clinical experts review and consult on which medications should have PAs, step therapies, or other utilization management strategies. Most importantly, our P&T Committee composed of practicing physicians and pharmacists work alongside our clients’ PBMs to advise on the best strategies for every medication.
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