Rise in Prior Authorizations Puts Doctors Off Brands

For many years, insurers have used prior authorizations for prescription medications. When formulary tiers were created by the insurance companies, certain medications that had to be approved previous to coverage were also created. The concept of a step-edit (documentation of failing a preferred medication first) quickly followed. However, the number of medications requiring prior approval and the documentation required for medicines to be approved jumped dramatically over the past few years. This phenomenon has become so severe that physicians may now be reluctant to prescribe any branded medications for fear of the dreaded prior authorization.

Several years ago, the main barrier to a branded medication (especially if new) was very high, non-preferred co-pay. Pharmaceutical companies successfully used coupons to remove that barrier. However, it appears that the insurers have caught up and have now begun to require prior authorizations on not only non-preferred branded medications, but even some “preferred” branded medications in lieu of higher tier co-pays. While the pharmaceutical companies have tried to counter this move with even better coupons deals (zero dollar co-pays, longer than a year value with a chance to renew), this will likely not help.

Endless Bureaucratic Hurdles

Prior authorizations are such a bureaucratic hurdle that larger practices have hired staff just to handle them. The typical prior authorization requires several phone calls just to determine the correct person to call, countless reiterations of the same demographic information, and non-transparent rules about what is required for medication approvals. If you ask any primary care physician what the worst thing about practicing medicine today would be (not including low reimbursement for primary care), the number one answer would likely be “prior authorization of medications.”

If pharma wants to be successful in getting physicians to prescribe branded medications, they are going to have to be more aggressive and more creative about assisting physicians with prior authorizations. Some companies with newer, extremely expensive biologics have done excellent work in this area, and other companies should follow their lead. While it would be unlikely that pharma could staff individual practitioner offices with employees dedicated to prior authorization, centralized similar services are certainly within reason. Several factors that would be important to physicians include:

1. A single number that physicians could call to get an actual person to answer the first time. Only the pertinent details are taken.

2. A single step process (from the providers standpoint at least) in which, after calling a centralized number and giving information, the company would take it from there.

3. Follow up with the pharmacy and the patient—by the company—so that the prescriber doesn’t need to worry whether or not the medication will be filled.

Steps similar to these would go a long way to restore providers’ willingness to prescribe newer, branded medications.

  • Matthew Mintz, M.D.

    Matthew Mintz, MD, FACP, is Associate Professor of Medicine and Director, Premier Access and Executive Services at The George Washington University School of Medicine in Washington, DC. Visit his blog at www.drmintz.com.


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