Tackling the Prior Authorization Challenge: A Critical Task for #Pharma | Pharmaguy's Insights Into Drug Industry News | Scoop.it

Talk with busy physicians and you’ll soon hear about the ever-increasing difficulty in getting approval for the medications that they believe are most appropriate for their patients. For pharma marketers, a superior efficacy, side effect and dosing profile is a necessary start, and a favorable managed care formulary position can be another positive step toward commercial success—but, more and more frequently, a prior authorization (PA) request must be approved before a medication can be dispensed and taken by the patient.


In other words, it’s not enough that the physician prescribes your product—something on which pharma often spends hundreds of millions of dollars in promotional investments, including advertising, sales, training, samples, conferences, and late phase research, all aimed at demonstrating that the product is best suited to treat certain therapeutic conditions. These efforts may lead a physician to write a prescription, yet there is no guarantee that the product will be dispensed, if the managed care plan restricts the patient from getting the medication.


Prior authorization (PA), is a stipulation by managed care organizations requiring a prescriber to seek approval for a specific drug by completing and submitting information before a drug can be reimbursed. The incidence and complexity of PAs is increasing, affecting more and more medications.


While most pharma executives are aware of PA requirements, they are sometimes unaware of the full implications. When a PA requirement is imposed, only 29% of patients end up with the originally prescribed product—and 40% end up abandoning therapy altogether. Not only is this negative for pharma and frustrating to prescribers, but it is even worse for those patients who don’t get the medication that could best treat their condition, or who don’t get any therapy at all. Further, the abandonment of prescriptions because of PA hurdles can have an “economic backlash” on the healthcare system as a result of additional office and emergency department visits, hospitalizations/re-admissions and other avoidable costs.


Most branded medicines face PA requirements across multiple managed care plans. While electronic PA processing (ePA) offers hope for a more efficient process in the future, for most managed care plans today the PA process can involve multiple steps for a physician practice: securing the correct form, filling it out with the required clinical information, appending clinical documentation in certain instances, submitting the form to the plan, and often completing and submitting a “follow-up, patient specific” form.


Further Reading:

  • “Adherent Health's Mobile Health Library Includes Prior Authorization App”; http://sco.lt/8slvcH