April 18, 2024

In the world of pharmacy benefits, one term that you will hear often is prior authorization. Often shortened to the acronym “PA” a prior authorization is a tool used by pharmacy benefit managers (PBMs) to control costs and ensure proper utilization of expensive or high-risk medications. Let’s dive into more on this tool and the value of prior authorization in pharmacy benefits.

What is a Prior Authorization?

For those of you familiar with the term “precertification” in the medical benefits world, a prior authorization is the equivalent on the pharmacy benefits side. Simply put, prior authorization is the steps plan members must take before receiving coverage for certain medications. Without prior authorization, the member may end up paying the entire cost or be denied the treatment.

Prior authorizations have historically been a tool used in specialty medication management. However, with the rise of prescribing off label for brand name medications, the scope of prior authorizations has expanded in recent years.

For example, it is common today for PBMs to report that 40-50% of the GLP-1 or GLP-1/GIP medications for diabetes are being prescribed to patients without diabetes. To ensure access for patients with proper diagnosis as well as to control for cost, PAs are now commonplace in this medication class.

Steps of a Prior Authorization

When a patient tries to fill a medication that requires prior authorization at the pharmacy through their pharmacy benefits, the pharmacy processing the claim will receive a reject message stating that the medication requires prior authorization. From there, the pharmacy should notify the prescriber’s office that the prescription needs a PA.

The prescriber, or one of their team members, will need to provide additional clinical information to the PBM. Once the provider’s office has submitted the required information, the PBM will decide to approve or deny the prior authorization. Note that if approved, the prior authorization usually only lasts for a defined period of time.

Common Reasons for Prior Authorizations

While Prior Authorizations can help with soaring medication treatment costs, that is not their sole goal. PAs are also tools for safe and effective use of medications.

PBMs employ PAs to:

  • Ensure proper diagnosis and use of treatment for FDA approved conditions and for plan covered indications
  • Ensure safe use of medications by confirming proper patient criteria, dosage and dosing regimen
  • Ensure safe use medications by confirming proper monitoring for treatment efficacy and side effects
  • Ensure safe and effective first line treatments in national published guidelines are used before jumping to treatments with increased risk and costs

Proper Prior Authorization Use

Some prescribers and patients will argue that PAs are not needed. Concern continues to be raised that PAs impact treatment timelines. Reports of PA leading to significant delays in therapy do exist and should not be ignored as a concern. However, when weighed against improper use of medications found during the PA process, they continue to be a necessary tool.

It is important to assess and continue to monitor your PBM’s approach to PAs and confirm that they are using these tools for the right reasons and in ways that do not unduly impact your plan members.

Questions to ask your PBM:

  • What is your PA turn around time and what process is in place to expedite a PA when a prescriber believes that is warranted?
  • How are your PA criteria built? Is it check boxes, or does it require clinical information such as chart notes and lab values to confirm medication use?
  • What are your PA approval rates? For those not approved, what is the outcome?
  • What is your process for PA appeals and how often are your decisions overturned?


Innovative Rx Strategies employes multiple clinical pharmacists to help support our clients in the assessment of all aspects of their plan, including the use of prior authorizations. In addition to supporting work within your PBM, the Innovative team can support the use and development of custom PA criteria to ensure all your outcomes for your plan and your members are achieved. Reach out to us today to learn more.

Reach out to our team