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Prescription Drug Prior Authorization Criteria |
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Prior authorization (PA), programs that
focus on specific drugs and require review and approval
for coverage, can play a crucial role in managing the cost
and safety of your prescription program. Yet too
often PA is a rubber stamp that doesn’t provide value
and causes member dissatisfaction - a lose-lose situation.
But that doesn’t mean you should abandon the concept.
A number of factors have made prior authorization programs
more important than ever, including:
- Increased prescription drug spending is propelled by
increases in the sales of a relatively small number of
top-selling drugs each year. Many of these new, expensive
and heavily advertised drugs are similar to existing medicines
and add little or no value.
- Medical mistakes are the fifth leading cause of death
in the U.S. and often involve prescription drugs.
- The same drug is often prescribed to treat various conditions.
Sometimes the plan covers a drug to treat certain conditions,
but not others.
The purpose of PA is to double check
that the prescription is appropriate and safe for the individual
– and eligible for coverage under the plan. Based
on your plan’s experience and coverage rules, Associates
& Wilson can help you select which drugs to include
in the program and develop rationale criteria based on best
practice guidelines. We’ll also make sure member communications
go beyond the typical frustrating denial letter that doesn’t
include the specific reason for the denial or what information
members need to do to receive coverage. The result is a
safer program that manages cost and educates members –
a win-win-win situation.
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