Insurance Companies and Pharmacy Benefits Managers (PBMs) Require Prior Authorization for Certain Prescription Medications in Order for Them to Be Covered.

Prescribers (i.e. Doctors, Nurse Practitioners, Physicians Assistants, etc.) must first determine if a medication requires prior authorization.

Next the prescriber must submit the prior authorization either via Fax or Electronic Submission.

Then the prior authorization tech at the PBM may need to enter the information from the fax into their own computer system.

A prior authorization pharmacist then reviews the request.

If the request is approved, the medication can be filled at the pharmacy.

If the request is denied, the rationale for the denial is sent back to the prescriber.

The prescriber can then provide additional clinical information or the request can be escalated to a medical director at the PBM.

Prior Authorizations generally take 13 business days and many physicians say that the delay in patient care results in adverse events and even unnecessary hospitalizations.

Correction: 25% of surveyed doctors said prior authorization resulted in an adverse health event and 16% said that delayed patient care resulted in hospitalizations.

PBM Explanation Video:    • How Prescription Drug Coverage Works:...  

Sources:
   • Prior Authorization Pharmacist | What...  

https://ehrintelligence.com/news/unde...

https://www.caremark.com/portal/asset...

https://emihealth.com/pdf/Prescriptio...

https://www.myprime.com/en.html

https://www.myprime.com/content/dam/p...

https://ehrintelligence.com/news/unde...
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