Prior Authorization

Specialty Pharmacy and Medical benefit Medication Prior Authorization (PA) criteria that is fully automated, digital, web-based, and includes effectiveness (ICD10), risk (FDA Alerts), utilization, genomic testing, step-therapy, cost, and options for care.
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Pro Pharma consultants evaluate benefit compliance as one of, or as the last reviewer, for multiple self-insureds and Health Plans. Benefit compliance is based on benefit coverage, FDA approved indications and/or support for therapy for extraordinary circumstances. Specialty medications are reviewed daily, on an “as needed” basis, or as a pre-certification review for FDA approved indications prior to the medical director review.

Prior Authorizations for specialty medications usually cover, but are not limited to –

  • FDA approved indications versus supplied diagnoses
  • Dosage compliance with prescribed indication(s)
  • Quantities compliant with benefit limitations
  • Genomic testing criteria
  • Pricing vs. contract requirements
  • Duplicate payments in medical and pharmacy
  • Multi-dose vs. single use dose
  • Opportunities for rebate capture


Important client benefits are –

  • Authorize based on strict benefit and FDA criteria for medication usage
  • Authorize based on fair and equitable cost reduction methodologies
  • Identify the patients that will receive the greatest benefit from the proposed therapy


For Pricing Call: (888) 701-5438