Prior Authorizations: What to Know

When doctors prescribe a medication to a patient, it does not guarantee the medication will be approved or covered under the patient’s pharmacy benefit plan. Some medications and medical products require preapproval by the patient’s pharmacy benefit plan, commonly known as prior authorization.

What is a Prior Authorization?

A prior authorization (PA) is an additional level of approval required by pharmacy benefit plans to ensure a medication is suitable for the patient and their condition. A PA can be used to determine the appropriate dosage of the medication, how it should be administered, and the length of time the patient should be on the selected medication. Products that typically require prior authorization are commonly:

• Subject to overuse, misuse, or off-label use
• Limited to a specific patient population
• Subject to significant safety concerns
• Used for a condition that is not included in the pharmacy benefit, such as cosmetic treatments¹

The Prior Authorization Process

If a patient’s medication requires PA, they should first ask their doctors if the medication is appropriate, if so, patients and their pharmacists can ask their doctor to fill out a PA form. Doctors will need to provide information on why they are prescribing the medication to the patient. Depending on the medication, they may need to provide the diagnosis, results of lab tests, or other information from the patient’s medical record.² Most pharmacy benefit providers allow patients or doctors to send the required information by phone, fax, or electronically.³ Once all the required information is gathered from the patient’s doctor, the patient’s pharmacy benefit plan can analyze the PA request.

Pharmacy benefit managers have their own set processes for reviewing and approving PAs. These processes may require internal physicians, as well as external practitioners, to review the PA. PA analysis criteria can differ and may be based on the latest FDA-approved product labeling, clinical evidence, national guidelines, and peer-reviewed literature published in scientific journals.¹ The process can take several days and depends on how complete and quickly information is provided and reviewed. The quicker a patient’s doctor fully completes a PA form, the quicker the patient can begin taking the prescription for their condition. The process is typically much faster if the PA request is submitted electronically.

If a PA request is approved, patients can fill their prescriptions, but coverage is still dependent on the patient’s pharmacy benefit plan cost share design. If a PA request is denied, patients can either ask their doctors if there’s another medication covered by their plan, choose to pay for the medication out of pocket, or submit an appeal with their doctor.²

The goal of PA is to safeguard patients from potentially harmful medications — not to prevent patients from getting the care they need. In addition to ensuring appropriate care, PAs can combat wasteful spend by identifying high-cost, low-value medications. For example, a pharmacy benefit plan’s drug formulary typically consists of medications with high clinical value and lower costs. If a patient’s medication is not on the formulary, PA may be required to check for value. Therefore, PAs assure the safest, most-effective, and most-valuable medications are allocated to patients.

National CooperativeRx: Prior Authorization Information

National CooperativeRx plan participants submit PA requests for non-specialty medications to CVS Caremark. For more information regarding CVS Caremark’s non-specialty medication PAs, please click here or watch this video.

If plan participants need to submit a PA request for specialty medications, these requests go through National CooperativeRx’s in-house specialty medication PA program. This is a new program as of January 1, 2023, implemented to improve patient experiences and save members money. Similar to our innovative clinical programs, this service is provided at no cost to our members. For more information regarding National CooperativeRx’s specialty medication PA program, please click here.