Key features of the PA focus are:

• Ensuring services delivered are clinically appropriate and cost-effective
• Eliminating barriers to obtain unusual, high-cost, or high-risk drugs when medically appropriate
• Encouraging open care-related dialogues among members, pharmacists, and prescribers

Administrative Prior Authorization

Administrative PAs are associated with routine benefit design exceptions such as vacation overrides, dosage change, and refill-too-soon exceptions. Administrative PA requests are reviewed by pharmacy technicians and support personnel.

Clinical Prior Authorization

Clinical PAs are associated with formulary and utilization management initiatives such as formulary alternative, quantity limit, step therapy, and medical necessity reviews. Clinical PA requests are conducted by our Prior Authorization Department of pharmacists, pharmacy technicians, and support personnel.

Real-time Prior Authorization

Real-time PA enables systematic review and execution of prior authorization protocols at the time of adjudication. We use all available data to verify the diagnosis and criteria are met to grant immediate PA approval. Real-time PA reduces member and physician objections, and provides quicker access to medically necessary and appropriate drug therapy.