Prior authorization (PA) presents a problem for both providers and their patients. Providers don’t have the time to research each patient’s formulary restrictions. And patients need to begin their new medication regimens as prescribed by their physicians – not as dictated by their insurance companies.
Though prior authorization was designed to control costs without negatively impacting outcomes, it’s a bureaucratic process that more often limits the efficient delivery of effective care.
It doesn’t have to be this way.
Providers agree. But prior authorization reform hasn’t yet been enacted. In its absence, pharmacists can save physicians time and help patients avoid administrative roadblocks by owning the prior authorization process. The result? More patients receiving the right medication at the right time – resulting in fewer gaps in care.
In this post, we’ll look at three ways pharmacists can support more efficient patient care throughout the prior authorization process.
1. Review plan policies and formularies to ease provider workloads
The prior authorization workflow is cumbersome. Even if a medication is on formulary, providers may not know that information until they find time to review a patient’s individual health plan. Too often that’s time-intensive work that could have been avoided.
What’s more: the availability of policy rules and formularies varies depending on the payer. They may be in hardcopy, downloadable as a PDF, or in an online database. So it can be difficult for providers to find this information.
Enter pharmacists. Pharmacists have the knowledge necessary to efficiently navigate varied payer plans and formularies – and the distinctions between a payer’s individual plans.
A payer may cover Lantus via their PPO, for example, though their HMO offers coverage of Levemir instead. Alternatively, the HMO may require completing the PA process for all insulin therapies, while patients covered by the PPO can receive therapies on formulary without prior authorization.
And if prior authorization is necessary, pharmacists can support and collaborate with care coordinators as they….
- Submit the claim.
- Communicate with the payer.
- Keep both the patient and physician up to date.
A patient may need to navigate the complex medication regimen most appropriate for their care. Alternatively, payers often require providers to prescribe the cheapest therapies before approving more expensive alternatives. But no matter the reason for prior authorization, the process takes time.
From formulary review to med history to approval, pharmacists can help make sure the right information arrives to where it needs to, when it needs to throughout the PA process. And with RxLive’s network of tech-powered pharmacists, existing pharmacy programs can leverage telehealth services to deliver more efficient care at scale.
2. Eliminate obstacles between patients and the medications they need
Each prior authorization request can require a patient to wait anywhere from 48 to 96 hours to get their medication. That’s a problem. The more obstacles there are between a patient and their medications, the more likely nonadherence becomes.
It’s clear prior authorization isn’t just an inefficiency – it’s a bureaucratic process that can lead directly to adverse medical events. Leveraging pharmacists’ understanding of drug therapies and individual payer formularies, however, helps ensure patients have the medication they need when they need it.
Say a patient is newly diagnosed with Type 2 Diabetes and requires insulin. Lantus is one of the most commonly prescribed long-acting insulin therapies. But if it’s not on formulary, prescribing Lantus will trigger a prior authorization process, leading to delayed therapy for the patient.
When a pharmacist leads your care coordination team, you can stop that process before it begins. Pharmacists can proactively review the formulary and let the provider know Levemir and Basaglar are covered as alternatives to Lantus.
And with that information at hand, the provider can initially prescribe Levemir or Basaglar, avoiding the PA process altogether. The result? The patient gets to start their insulin therapy three to four days earlier than if they were prescribed a drug off formulary.
3. Efficiently triage medication regimens to identify cost-effective alternatives
We’ve written before about how pharmacists can help save money with biosimilars and generic drugs. But when pharmacists triage medication alternatives it doesn’t just drive down costs – it improves health by improving patients’ access to care.
Say a provider writes a prescription for Tradjenta. Though not a first-line medication, it helps as an additional therapy to help keep a patient’s blood sugar down. But payers may not see the value in adding an additional high-cost prescription to a patient’s regimen and reject the claim. This leaves providers with two options:
- Appeal the payer’s rejection.
- Prescribe a different medication.
In the best case scenario, the payer may identify a lower-cost option such as Januvia in their rejection. But even in this case the patient’s care is delayed.
When pharmacists are embedded into your network’s care team, they can help recognize alternative medications like Januvia ahead of time. This not only avoids navigating the prior authorization process, it eliminates spending additional time on an appeal or determining a new medication.
The result? Patients receive all the care prescribed by their physician.
Pharmacists balance the delivery of efficient, effective care
When payers determine a medication requires a prior authorization, it’s almost always a matter of cost. And while health is the primary concern for patients and providers,insurance companies are always on the lookout for cheaper medications.
The facts are clear: the more quickly patients receive the medications they need, the likelier they are to stay healthier, longer. That’s why payers, providers, and patients all can view pharmacists like a fulcrum: they bring balance to cost-effective care for all links across the healthcare chain.Contact us to learn more about how RXL empowers the efficient delivery of value-based care.
