Prior authorization in pharmacies

[ZakMeister]

Advertisement - Members don't see this ad

I don't get why Pharmacies can't do prior authorizations of almost any medication that needs one, as some contracted "specialty" pharmacies are allowed by PBMs to submit PA's for biologics like Humira/Prolia etc. What makes a certain pharmacy or even a drug eligible for a PA ?


Sent from my iPhone using SDN mobile

 

[Jackanese]

I don't get why Pharmacies can't do prior authorizations of almost any medication that needs one, as some contracted "specialty" pharmacies are allowed by PBMs to submit PA's for biologics like Humira/Prolia etc. What makes a certain pharmacy or even a drug eligible for a PA ?


Sent from my iPhone using SDN mobile

I work as a prior authorization pharmacist. You're correct, we don't accept information from most retail pharmacies. The prior auth process is mostly a diagnosis review, along with formulary alternatives, lab results (T score, LDL level, etc), chart notes, etc. Most retail pharmacist don't even know what the medication is being prescribed for.

 

[ZakMeister]

I work as a prior authorization pharmacist. You're correct, we don't accept information from most retail pharmacies. The prior auth process is mostly a diagnosis review, along with formulary alternatives, lab results (T score, LDL level, etc), chart notes, etc.

I am gonna assume you work for a PBM then. So the specialty pharmacists contract with you guys for certain biologics that require PAs correct?I used Approve rx a lot for processing those docs and faxing them over to the insurance companies. For CVS n Walgreens, I believe their specialty branch takes care of it


Sent from my iPhone using SDN mobile

 

[Jackanese]

I am gonna assume you work for a PBM then. So the specialty pharmacists contract with you guys for certain biologics that require PAs correct?I used Approve rx a lot for processing those docs and faxing them over to the insurance companies. For CVS n Walgreens, I believe their specialty branch takes care of it


Sent from my iPhone using SDN mobile

Yes. I do work for PBM. Certain specialty pharmacies are contracted with us to do prior auth. The only one I'm aware of is our in house specialty pharmacy.

 

[wagrxm2000]

Most retail pharmacist don't even know what the medication is being prescribed for.

Huh?

 

[Jackanese]

Huh?

Sorry. What I meant was prescribers usually do not put the diagnosis on the prescription. For the most part, a PA review is mainly a review of the diagnosis.

 

[npage148]

That's not really what it sounded like you said

 

[PikminOC]

So if I write the meds is for adhd on the prescription, the pharmacist can do the pa?

 

[doublehh03]

So if I write the meds is for adhd on the prescription, the pharmacist can do the pa?

Not necessarily. Most prior authorizations involve the prescriber and the insurance. However, in some instances (like Medicaid), if you provide a diagnosis code, we can initiate the P/A and get an answer.

 

[CynicalIntern]

So if I write the meds is for adhd on the prescription, the pharmacist can do the pa?

99% of plans, if I call the insurance and tell them I'm a pharmacist, they'll tell me to GTFO and have the doctor's janitor or someone more qualified to do the authorizations.

Most of these pharmacists get around it either by lying and telling the insurance they're a "patient care coordinator" or "medical assistant," or by getting the PA forms, filling them out, and signing their own name, and leaving it to the insurance company to determine their title.

Some of these pharmacists do this legitimately with the consent of the MD. Others just do whatever is easiest to get an approval - aka lying and giving the right answers. Granted, plenty of medical staffs do the exact same thing.

 

[PikminOC]

I don't lie on prior auths. I only do them if the med is expensive. And I tell the truth. If it's not covered, that's not my problem. I will not commit fraud for coverage