What is a Prior Authorization?

A prior authorization refers to the utilization management method used by many healthcare companies to require preapproval or precertification before they will cover care or services; more or less, the insurance company wants it clearly explained as to why they should reasonably pay for whatever is being requested. In the world of pharmacy, this is particularly pertinent for those seeking new or costly medication therapies. There are a wide variety of prior authorization forms and requirements, as they are generally plan-specific as well as therapy-specific.

 

For example, if a patient with rheumatoid arthritis is prescribed adalimumab, even though it is a very common therapy currently, it is still high-cost and high-touch; to ensure the patient is receiving appropriate treatment, the PA process is where the insurance mandates the prescriber to explain further why that specific medication is the best option for that specific patient before they will pay anything towards the cost of the prescription.