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Testing alternatives to prior authorization

MANAGED CARE January 2010. © MediMedia USA
The Formulary Files

Testing alternatives to prior authorization

MANAGED CARE January 2010. ©MediMedia USA













“Physicians don’t like prior authorization,” says Steven E. Wegner, JD, MD, chairman of the North Carolina Community Care Network, made up of 15 networks with more than 3,500 physicians and 1 million Medicaid and SCHIP enrollees.

“They have to call the insurers, it’s time-consuming, and it’s frustrating trying to understand the criteria that a health plan uses to determine drug coverage.”

That sums up the exasperation providers feel when dealing with prior authorization guidelines, and that’s why a program the network began has him excited.

The network wanted to determine whether implementing an instant approval process could improve gaps in therapy for members and increase provider satisfaction. When a member tries to obtain a prescription and the pharmacy says there will be a wait while authorization is sought, members have been known to walk out of the pharmacy and not come back to pick up the prescription.

The North Carolina Medicaid proton pump inhibitor (PPI) prior authorization (PA) program determined which PPIs would require prior approval.

Providers were given three prescription options: use of a preferred PPI without any coverage restrictions; use of a nonpreferred PPI and the traditional PA process of contacting a PBM or other third-party administrator; or the use of a nonpreferred PPI, with a check box for “meets criteria.”

Checking this box bypassed the PA process. It could mean that the patient had been prescribed an approved PPI but it had not relieved symptoms, had been diagnosed with esophagitis grade C or D, or had difficulty swallowing tablets or capsules.

The researchers found that before the program started, the market share of preferred PPIs was 17.5 percent to 19.3 percent. It increased to 76.3 percent in the first month of the program. After the first 7 months of the program, the preferred PPIs lost minimal market share (7.1% percentage points). Monthly drug costs dropped from a pre-PA mean of $4 million to a post-PA mean of $1.5 million.

Not bad at all.

Monthly drug costs and market share of preferred PPIs

Pre-rebate drug cost ($ millions)

Start of prior authorization or instant approval

Preferred drugs’ market share (%)

Source: Wegner SE, Trygstad TK, Dobson LA, Lawrence WW, Steiner BD. A physician-friendly alternative to prior authorization for prescription drugs. Am J Manag Care. 2009;15(12):e115–e122.

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