Certain drugs on a formulary may require prior authorization (PA) before a patient can receive the medication. Drug Prior Authorization is a utilization management tool that requires the prescriber to provide clinical information (e.g. lab values, chart notes, etc.) in order for the payer to make a determination whether it will pay for the drug.
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· “Prescribers often are not aware that a PA is needed until the prescription claim is rejected at the pharmacy. This leads to delays in 1) the opportunity to discuss the PA process with the patient 2) the potential to prescribe another medication, and 3) the patient’s treatment beginning as anticipated.“
· “Pharmacists are often playing middlemen, contacting the prescriber to initiate a PA, and notifying the patient of the coverage restriction. They spend time contacting the prescriber, either by phone, fax or via a secure transaction. They may also contact the payer to determine the status of the PA request and update the patient.”