1. Greater Chicago Epilepsy Consumer Conference 2016
PRIOR AUTHORIZATION
Patricia Fischer, RN, CCRP

2. I NEED WHAT? Prior Authorization
A mechanism by which the health care provider ordering a specific medication conveys to the third party payor (insurance company, Medicare, Medicaid Managed Care Organization - MCO) the justification for the use of that particular medication in that individual
A World-Class Education, A World-Class City

3. Why? Generally applies to newer, more costly medications
Other considerations:
“off-label” use
Avoid duplicate therapy
Interactions with other medications
Safe medication use – benefits vs side effects
Ensure requirements for use of specific drugs in special populations are met
A World-Class Education, A World-Class City

4. Common Prior Authorization Scenarios
Medication ordered by the health care provider is not on the payor’s drug plan list (formulary) - formulary exception*
Dose ordered is higher than usual (exceeds the number of pills [quantity limit] allowed by the plan) - formulary exception*
Drug previously received as part of plan has been removed - formulary exception*
A World-Class Education, A World-Class City

5. Common Prior Authorization Scenarios
Medication is identified on the payor’s drug list as requiring Prior Authorization (PA) (designated as “Non-Preferred”)
The requirement that a different drug be tried before the drug being prescribed will be covered (Step Therapy) – formulary exception*
A World-Class Education, A World-Class City

6. My plan has a Step Therapy requirement
Step Therapy is a process used by health insurers to control costs and risks posed by prescription drugs
Also referred to as “Fail First”
Step Therapy is a type of Prior Authorization requirement
Employs the use of one or more drugs (usually generic) before allowing a “step up” to another medication that may be more costly or that has greater risks associated with it’s use
A World-Class Education, A World-Class City

7. Prior Authorization Process
Program specific requirements
Complete and fax plan-specific paper form
Initiate and complete by telephone
Complete forms electronically at the plan’s website
May be initiated by the patient or their representative (may require specific designation) with provider verification
A World-Class Education, A World-Class City

8. Application Process
Most plans provide determination of their review by 72 hours
Expedited review (24 hours) may be requested if the provider indicates delay may be harmful to the patient’s health
Notification of approval to the provider by mail (in most cases)
A World-Class Education, A World-Class City

9. What if the Prior Authorization request is denied?
Appeal process
Can be initiated by patient or provider but will require additional information, copy of relevant medical records
Refer to explanation in Denial Notice to determine what further information may result in successful appeal
Usually requires up to 7 days for response to the appear request, expedited decisions within 72 hours if delay will be harmful to the patient
A World-Class Education, A World-Class City

10. The Epilepsy Foundation of Greater Chicago advocates for you!
Worked to ensure:
Prior Authorization is not required for non-preferred epilepsy medications for Illinois Medicaid MCO participants with a diagnosis of epilepsy/seizure disorder in Department records
Transparency in Step Therapy process, override options:
if required drug is not appropriate
if patient has failed the drug previously
if patient is stable on their present therapy from a previous or current health plan
A World-Class Education, A World-Class City

11. Partnering In Your Care
Bring copy of your insurer’s current drug plan list/formulary to your appointment
Be aware: lists change – quarterly, annually!
Ensure your provider has complete, accurate information about medications previously tried and your response to each
If your pharmacy indicates a Prior Authorization or formulary exception is required, notify your provider & EFGC
A World-Class Education, A World-Class City