Prior authorization training for pharmacist

[RxNnempa]

I'm a clinical pharmacist and worked in the hospital but needed a break and wanting to take on prior authorization pharmacist job. Never worked in retail and wondering if there is a stuff like "prior authroization certification training" I can take. Does anyone have any idea or does such thing even exist?

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[zelman]

I'm a clinical pharmacist and worked in the hospital but needed a break and wanting to take on prior authorization pharmacist job. Never worked in retail and wondering if there is a stuff like "prior authroization certification training" I can take. Does anyone have any idea or does such thing even exist?

Probably not. Did you approve non-formulary drugs at the hospital?

 

[BidingMyTime]

Certification? Prior authorization is all on-the-job training. What and how often you approve PA's, depends on each individual companies formulary (which will differ based on kick backs, um no that would be illegal, I mean based on "rebates" that they get for certain brand name drugs.)

 

[Saisri_PharmStdnt]

I work in a Prior Authorization dept. and have 12 or so pharmacists at my disposal.. Have questions?

Certification? Prior authorization is all on-the-job training. What and how often you approve PA's, depends on each individual companies formulary (which will differ based on kick backs, um no that would be illegal, I mean based on "rebates" that they get for certain brand name drugs.)

Yep, this is all correct. We work for a very specific plan, and our Prior Authorization drug list probably differs at least in part from many others out there. The list is based on $$ and rebates, diagnosis, abuse potential, etc.. Prior Auth can limit quantity, or access to a demographic (male vs female, or adult vs pediatric), or whether you can access the drug at all (no quantity restriction from insurance). As a clinical pharmacist in this setting, you apply the criteria restrictions of a plan to the patient.

An example I give my team all the time is:

If a prescriber requested Ambien 10mg 1 hs prn, but the provided diagnosis was Depression, as a clinical pharmacist you might ask if the patient also has Insomnia (in our case, the official diagnosis on the criteria). If they do, it's approvable. If they don't, then as a clinical pharmacist, you (and your license) can deny coverage of the medication for not meeting the Client/Plan's criteria.

 

[JustAnotherRph]

There is no certification course and it is pretty much on the job training to do PA's. There isn't really rocket science to standard PA. Either there is criteria or it defaults to standard non-form criteria of try/fail 2 formulary agents. The specialty PA's can get convoluted but that is assuming the doctor's office sends all the records needed to review.
Most companies I have worked for have taken their hiring pool from their contractor pool. They can get a contract pharmacist quicker and determine if they are a good fit to offer full time employment too. That may be the way to go if you really want to get in managed care. Most of the other positions in managed care are impossible to get unless you have managed care experience.

 

[Saisri_PharmStdnt]

Also accurate - do we work for the same plan? haha

 

[RxNnempa]

There is no certification course and it is pretty much on the job training to do PA's. There isn't really rocket science to standard PA. Either there is criteria or it defaults to standard non-form criteria of try/fail 2 formulary agents. The specialty PA's can get convoluted but that is assuming the doctor's office sends all the records needed to review.
Most companies I have worked for have taken their hiring pool from their contractor pool. They can get a contract pharmacist quicker and determine if they are a good fit to offer full time employment too. That may be the way to go if you really want to get in managed care. Most of the other positions in managed care are impossible to get unless you have managed care experience.

Thank you

 

[RxNnempa]

I work in a Prior Authorization dept. and have 12 or so pharmacists at my disposal.. Have questions?




Yep, this is all correct. We work for a very specific plan, and our Prior Authorization drug list probably differs at least in part from many others out there. The list is based on $$ and rebates, diagnosis, abuse potential, etc.. Prior Auth can limit quantity, or access to a demographic (male vs female, or adult vs pediatric), or whether you can access the drug at all (no quantity restriction from insurance). As a clinical pharmacist in this setting, you apply the criteria restrictions of a plan to the patient.

An example I give my team all the time is:

If a prescriber requested Ambien 10mg 1 hs prn, but the provided diagnosis was Depression, as a clinical pharmacist you might ask if the patient also has Insomnia (in our case, the official diagnosis on the criteria). If they do, it's approvable. If they don't, then as a clinical pharmacist, you (and your license) can deny coverage of the medication for not meeting the Client/Plan's criteria.

Thank you

 

[RxNnempa]

Certification? Prior authorization is all on-the-job training. What and how often you approve PA's, depends on each individual companies formulary (which will differ based on kick backs, um no that would be illegal, I mean based on "rebates" that they get for certain brand name drugs.)

Thank you

 

[914451]

Your best bet as I've experienced it is to get in by being a temp. Large insurance companies hire a large amount of temps starting right about now in preparation for Medicare open enrollment. Even at my company, all of our newer pharmacists that are now on staff were temps for us first.

 

[Saisri_PharmStdnt]

That's what we do. We bring in contingents, then convert to full-time if it works out. I think our department alone is posting 2 contingent spots in the next couple weeks if they aren't already posted. If you're in the Phoenix area........

 

[Corytrade]

Just be really good at saying no, and making up reasons why you won't let PCPs prescribe medications.

 

[Saisri_PharmStdnt]

Just be really good at saying no, and making up reasons why you won't let PCPs prescribe medications.

Now that isn't fair. We have roughly an 85% approval rate. (this plan won't cover Cialis for ED only for BPH, so that's the bulk of the 15% of denials). We try to approve as much as possible. Where are hands get tied are the plan exclusions and targeted therapies.

If a medication is for OA of the Knee, we're not going to approve it for OA of the hip (or any other body part). If a medication is for Hep-C Genotype 1, we're not going to approve Genotype 5. Things like that.

 

[JustAnotherRph]

Also accurate - do we work for the same plan? haha

That's what we do. We bring in contingents, then convert to full-time if it works out. I think our department alone is posting 2 contingent spots in the next couple weeks if they aren't already posted. If you're in the Phoenix area........

Possibly. I haven't been a PA pharmacist in over 5 years and have moved up the food chain in managed care.

 

[Saisri_PharmStdnt]

Possibly. I haven't been a PA pharmacist in over 5 years and have moved up the food chain in managed care.

Maybe then 🙂 Well, good for you for movin' on up! 🙂

 

[minette]

That's what we do. We bring in contingents, then convert to full-time if it works out. I think our department alone is posting 2 contingent spots in the next couple weeks if they aren't already posted. If you're in the Phoenix area........

I also work in managed care in Phoenix...

 

[914451]

Now that isn't fair. We have roughly an 85% approval rate. (this plan won't cover Cialis for ED only for BPH, so that's the bulk of the 15% of denials). We try to approve as much as possible. Where are hands get tied are the plan exclusions and targeted therapies.

If a medication is for OA of the Knee, we're not going to approve it for OA of the hip (or any other body part). If a medication is for Hep-C Genotype 1, we're not going to approve Genotype 5. Things like that.

My approvalenial rate ranges from 50:50 to 80:20 depending on what product I'm working under. Medicare plans tend to be very lenient to avoid regulatory scrutiny and to avoid low patient satisfaction scores. Medicaid and commercial plans in my experience have always been very restrictive.

 

[914451]

I don't know if there is a study out there on this, but my anecdotal feeling is that pharmacy benefits and utilization activities are extremely heterogeneous -- largely driven by audit results and team consensus. Some plans are super strict about FDA approved diagnoses and following criteria, while other plans are willing to approve everything for "continuation of therapy" or "stability."

This is partially why on the job training is really the only way to learn the trade. Also, managed care UM is a huge circle jerk. Beware the culture of pure internal hiring and ego peddling.

 

[Apotheker2015]

I'm a clinical pharmacist and worked in the hospital but needed a break and wanting to take on prior authorization pharmacist job. Never worked in retail and wondering if there is a stuff like "prior authroization certification training" I can take. Does anyone have any idea or does such thing even exist?

Your employer will train you. It's usually in a class environment for 4 to 8 weeks. All you're basically doing is following criteria to approve or deny drugs. The algorithms are embedded into the software most of the time. It will help if you have a good memory and recall the criteria.