Important note: Information in this article was accurate in April 2002. The state of the art may have changed since the publication date.
Treatment Issues: Newsletter of Experimental AIDS Therapies - Volume 16, Number 4, April 2002
Example of an actual prior authorization procedure used by an HMO in Texas.
Applying for Prior Authorization
If you are currently taking one of the restricted medications, your doctor may request a review by calling the Plan's pharmacy benefits manager (PBM).
If review is not sought in advance, the process for prior authorization is as follows:
1. The prescription is presented to the pharmacy. In other words, if you need a refill for your ongoing treatment or you need a new medicine, but your doctor forgot to check with the PBM first...
2. When the pharmacy submits the prescription to the PBM, an on-line message tells the pharmacist that authorization is necessary. Sorry, there's a problem. No information about getting an emergency supply. No warning of possible risks to your health from discontinuing or delaying a treatment.
The pharmacist is provided with the PBM's phone number to begin the authorization process. That's if the pharmacist has the time or patience to wait on the phone. More likely he says, "Come back tomorrow." Or simply, "Sorry it was denied."
3. The member should ask their prescribing physician to contact the PBM to discuss the criteria for use and other clinical parameters. The burden is on you. If you really want the drug you need to go back to your doctor and tell him he has to call the PBM with a good reason why you should have that medicine. Or maybe you just give up after hearing, "Sorry, it was denied."
4. Coverage is decided and patient and physician receive notice of either approval or denial. If they approve the prescription (and you're not in the hospital from complications), you can go back to the pharmacy and pick up your medicine.
Hopefully, no more than a week has gone by.
If they deny authorization, go back to your doctor and start all over again.
If coverage is denied, your physician can request an appeal. With an appeal, new information MUST be provided. It's not enough to say that you really need this drug... your doctor has to come up with another reason why you should be treated the way he thinks is best.
Good luck!
The bottom line for any fair prior authorization (PA) system should be that no patient is denied medicine simply because arbitrary procedures haven't been followed.
The patient shows up at the pharmacy with a prescription. The script is entered into the pharmacist's computer, which communicates with the PBM. The PBM computer recognizes that the script is for a listed drug but the doctor hasn't obtained PA. At this point the PBM computer should:
1) Approve a 30 day supply of the drug for the patient;
2) Inform the pharmacist that a temporary exemption has been issued and print out a written notification to the patient;
3) Send a written notice to the doctor that this drug requires PA and tell the doctor how to request authorization. Follow up with phone calls to the doctor;
4) Insure that all problems are resolved before the patient returns for a refill.
In cases when the doctor has correctly obtained PA, the patient should present the script to the pharmacist whose computer will confirm the authorization and approve dispensing the drug. No special action is required of the patient or pharmacist and the confirmation is handled transparently. Once authorized, PA should remain in effect for one year.
In cases when PA is denied but the doctor states the drug is medically necessary for the patient, PA must be granted and the drug must be dispensed.
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