Prior Authorization is a practice by payers (health insurance plans and Pharmacy Benefit Managers – PBMs) that requires a patient, doctor, or pharmacy to seek special permission from the payer to provide a patient with a treatment already covered by the patient’s health plan. Prior authorization rules are set by the payer and differ for each payer. The rules may require a patient, doctor, or pharmacy to submit additional information and receive approval before providing the medication or treatment. The original purpose of prior authorization was to limit unnecessary and potentially fraudulent insurance claims. Differing prior authorization rules, the extra information required, and the extra time needed to meet these requirements and receive authorization can cause several problems. Patients, doctors, and pharmacists may have trouble understanding the extra requirements. The extra work involved increases costs to payers, doctors, and pharmacists. It can also delay patients from receiving necessary care, which can harm the patient’s health and lead to complications (which require additional treatment).
A growing problem for people with chronic medical conditions is the requirement to get prior authorization for every medication refill. Many people with bleeding disorders regularly use clotting medication to control bleeding and may need monthly refills. Because there is no cure for bleeding disorders they may need a prior authorization every month for medication the health plan already promised to cover. Delays and denials mean the patient can go without factor, risking serious bleeding and lasting complications.
WHAT IS BEING DONE
Bill A.7129 (Gottfried) / S.6435a (Breslin) creates common sense guidelines for the use of prior authorization by health plans and PBM’s. The guidelines are designed to allow for prior authorization to be used in a way which doesn’t delay treatment for patients or add unnecessarily to the burden on medical staff. The guidelines: