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.
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
