PAs Re-Defined: Ensuring Meds Are Appropriate & Cost-Effective for Members

Prior Authorizations, commonly referred to as prior auths or PAs, are designed to ensure that certain prescription drugs are used for appropriate medical purposes as approved by the Food and Drug Administration (FDA). When a member goes to the pharmacy counter and is told their prescription needs a PA, their first thought likely is worry or frustration. Members usually don’t know what goes on behind the scenes and definitely don’t like having a delay in getting their medication. In the end, PAs get a bad rap – and HR leaders don’t like hearing from unhappy employees.
This presents a critical problem because PAs play an important strategic role in ensuring that members receive only the most clinically appropriate, cost-effective medications for their condition. PAs help plan sponsors ensure that all medications covered by the employer-sponsored pharmacy plan are safe and effective, at the lowest net cost.

The PA Value Potential

No one wants to risk a client relationship over misunderstood processes and service issues, like PAs. At RxBenefits, we make it simple. Our PA process is designed with clients and members in mind, functioning independently from the PBM. We focus on ensuring medication appropriateness of the drugs posing the greatest risk to the plan, so that employers stop paying for drugs that don’t matter to preserve funding for those that do.

When a member is told their prescription needs a PA, it means we need to make sure the prescribed medicine and dose is clinically appropriate for their condition. Typically this requires obtaining additional information from the prescriber so that an accurate decision can be made. An independent clinical pharmacist manually reviews the claim and supporting documentation to reach a decision.

More often than not, the member is notified that the prescribed medication is approved. However, there could be a time when the medication is not approved as prescribed and needs to be adjusted by the prescriber. In those cases, the prescribed dosing could get adjusted or the medication switched to a more clinically appropriate, approved alternative. This may sound similar to many PBM PA processes, but our PA process adds a uniquely human touch.

The RxBenefits Difference

RxBenefits’ clinical pharmacists carefully evaluate each claim and the supporting medical documentation, whereas PBMs rely on automated machine-based decisions unless the member submits an appeal. Our team also conducts coordinated outreach to seek external specialist opinions or intervene with prescribers when necessary. The result is a transparent process where PAs have strategic value as part of a holistic cost management and health optimization solution. Employers receive greater visibility into the PA decisions impacting their members so that they understand the overall value for their pharmacy benefits plan.

Read our free PBO Clinical Strategies Playbook to learn more about how RxBenefits’ Rx utilization management strategies help employers eliminate waste and optimize therapy while improving the benefit value for members.



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