Why Do Some Prescriptions Require Prior Authorization?

There are some frustrations certain pharmacists deal with in their practice settings that others hardly ever encounter at all. For the community or health-system pharmacist or pharmacy technician, one such headache is prior authorization (PA).

I sometimes find myself daydreaming about a pharmacy job that doesn’t encounter PAs. But, having dealt with them for more than 20 years, I think I’ve developed a fairly comprehensive method for handling them, and it would be a shame to let all that knowledge go to waste.

This article is for pharmacists thinking about retail pharmacy or pharmacy students considering it as a career. It might also be appropriate for new retail pharmacists or pharmacists in other settings who are curious about PAs.

Of course, I’m not suggesting other pharmacists don’t encounter PAs. If you’re a clinical pharmacist working in an ambulatory care setting, you may have dealt with the frustration of patients telling you their prescribed drug couldn’t be filled because it required a PA. And, of course, if you work in managed care, you may live and breathe PAs.

My own familiarity with PAs stems from a long career in community pharmacy, as well as 7 years spent exclusively working as a formulary analyst, when I did nothing but research PA criteria for various drug classes, including oncology and specialty pharmaceuticals.

What Is a PA?

It’s a tool used by managed care (eg, insurance companies) to make sure the prescribed medication is appropriate and necessary. When a particular drug requires a PA, the pharmacy will generally receive a “rejected” claim from the insurance company when attempting to fill it. The rejection will simply read, “Prior Authorization Required.”

PAs are specific to each health plan. So, while some drugs may require a PA no matter the type of insurance, other medications may vary depending on the plan involved. That’s why it’s often hard to predict whether or not a prescription will need a PA prior to running the claim.

Why Do Certain Drugs Require PAs?

That’s a bit of a loaded question. Some pharmacists would simply say, “It’s all about money.” Although that’s true in some sense, it hardly explains the whole situation.

To be a bit more diplomatic, I explain to students and new pharmacists and technicians that a drug will require a PA if the health plan wants to ensure:

• Other, less expensive (and yet appropriate) medications have been tried and failed first.
• The medication is actually appropriate for the patient (eg, the patient has a diagnosis matching the drug indication).
• The patient and prescriber have been properly educated on the risks associated with the medication.
• The patient intends to comply with the treatment plan necessary to improve the chances of success with the drug therapy.

A PA will also pop up if the health plan deems the drug both new and expensive and hasn’t yet developed treatment guidelines, thus requiring a case-by-case review. Or, if the prescription is written for a drug that’s unusual for the patient’s age or gender, or in an unusual quantity or dosage.

This list isn’t comprehensive, but it probably explains why the majority of PAs on medications exist.

How Do Pharmacies Manage Prescriptions Requiring PAs?

Although large chain pharmacies may have specific policies in place for managing medications requiring PAs, pharmacy staff are often left to develop a method that works for them. Ideally, the process involves providing some sort of communication with the patient (and possibly with the prescriber) about the issue related to the prescription.

Some pharmacies will call the prescriber, while others will fax a form. Some will use online services developed exclusively for the purpose of dealing with prescriptions requiring PAs. The best processes also keep the pharmacy involved so the prescription isn’t just abandoned.

How Do You Explain PAs to Patients?

This is where many new pharmacists and technicians often stumble. I’ve seen pharmacy staff simply tell a bewildered patient, “Your drug needs a PA, so you’ll have to talk to your doctor.” That may make perfect sense to the staff, but it often means nothing to the patient.

Sometimes, it’s hard for pharmacists and technicians to imagine what it would be like to have no idea what a “prior authorization”—much less a “PA”—means. Therefore, we fumble when trying to communicate it effectively.

I tell patients something like:

Your doctor has written a prescription for XYZ medication. Unfortunately, your insurance requires your doctor to get special authorization (‘special’ authorization is often more meaningful and descriptive than ‘prior’) for this medicine before they’ll approve it for you. We’ve notified your doctor, and you should probably give them a couple of days to process the request. If you need the medicine sooner, you can pay for it (no guarantee you’ll get reimbursed), or you could call your doctor and ask for an alternative.

PAs aren’t the most fun part of the job, but they do present an opportunity to assist patients and providers in a meaningful way that helps control the cost of health care while still aiding patients in getting the medication they need.