TY - JOUR
AU - Graham,, Jove
AB - Abstract Objective To determine the amount of variation in numbers and types of medications requiring prior authorization (PA) by insurance plan and type. Methods Most health insurance companies require PA for medications to ensure safe and effective use and contain costs. We generated 4 lists of medications that required PA during 2017 for commercial, marketplace, Medicaid, and Medicare plans. We aggregated medications according to the generic medication name equivalent using codes and medication names. We compared these medications to assess how many of the medications required PA by 1, 2, 3, or all 4 of the insurance plans. We counted all prescription orders written for a patient age 18 years or older with health plan insurance during 2017 for any of the medications that appeared on the health plan’s PA lists by querying the electronic health record. Results PA was required for 600 unique medications in 2017 across the 4 plans. Of 691,457 prescription orders written for 114,159 members, 31,631 (5%) were written for 1 of the 600 medications that required PA by at least 1 insurance plan. There were 12,540 medication orders (written for 6,642 members) that potentially required PA. The marketplace plan required PA for the greatest number of medications (440), followed by the Medicare (272), commercial (271), and Medicaid (72) plans. The most commonly prescribed classes of medications for which PA was required by at least 1 plan were antihyperlipidemics (22% of orders potentially requiring PA), narcotic analgesics (13%), hypnotics (12%), antidiabetic medications (9%), and antidepressants (9%). For only 25% of medications (151 of 600) was PA required by at least 3 plans, and for only 5% (32 of 600) was PA required by all 4 insurance types. Conclusion Medications requiring PA can differ within a single health insurance company, but this variation may be unavoidable due to external factors. insurance, medications, prior authorization KEY POINTS Relatively few medications are subject to the prior authorization process, but many organizations have focused on developing systems to improve this process. Variation in numbers and types of medications requiring prior authorization can differ within health insurance products at a single health insurance company. Future work should evaluate the impact of differing prior authorization requirements on outcomes such as physician workload, patient satisfaction, approval rates, and time to approval. Health insurance companies in the United States have implemented various strategies to promote evidence-based practice and manage costs.1 Prior authorization (PA) is one of those strategies and is a process that requires a healthcare professional to seek prior approval of a procedure, service, device, or medication before the patient receives it in order to qualify for reimbursement. For example, to obtain a medication that requires PA for a patient, a healthcare professional must complete a form consisting of required elements about the patient’s health indicating that the medication is appropriate and necessary for his or her care. A major goal of PA is to improve the utilization of medications. The Academy of Managed Care Pharmacy Professional Practice Committee has highlighted 9 concepts for effective utilization of PA: (1) patient safety and appropriate medication use, (2) clinical decision making, (3) evidence-based review criteria, (4) automated decision support, (5) transparency and advanced notice, (6) emergency access, (7) provider collaboration, (8) the need for timeliness and avoiding disruptions in therapy, and (9) cost-effectiveness and value.2 These concepts have been implemented in a variety of ways by health insurance companies, resulting in variation in both the process and medications covered by different insurance products within and between insurers. Prior studies have reported that public payors (eg, Medicare and Medicaid in the state of Washington) had different requirements for atypical antipsychotics, with only 5% to 21% overlap between plans,3 while another study examining Medicaid plans across the country and their coverage of antirheumatic medications found similar results.4 In a multipayor health system, however, the unintended consequences of these differences—both between and within plans—are associated with increased burden and costs to healthcare facilities due to the time spent researching varying requirements, completing forms, and communicating with insurers. The objective of the study described here was to compare and contrast numbers and types of medications requiring PA at 4 insurance plans (a commercial, a marketplace, a Medicaid, and a Medicare plan) administered by one insurance company. In addition, we examined the number of prescription orders from an affiliated healthcare system for those medications to assess the volume of care potentially affected within a population. Methods The study was conducted within the context of an insurance company with approximately 540,000 members and an integrated delivery network with 12 hospitals and 138 primary and specialty clinics located in central and northeastern Pennsylvania that provides healthcare to over 2.6 million individuals. Approximately one-third of the individuals who are treated at the affiliated health system carry insurance from this company. We aimed to describe the variation in medications requiring PA across 4 types of health insurance plans—commercial, marketplace (plans offered as part of the Affordable Care Act), Medicaid, and Medicare—offered and to determine the volume of outpatient prescription orders for those medications written by providers at the health system during 2017. First, data were obtained from the insurance company, including documentation that listed prescription medications and whether they required PA (for the pharmacy insurance benefit) by each of the 4 plan types. Medications were identified by simple generic name and by RxNorm code (RxNorm is a normalized coding system maintained by the National Library of Medicine). We examined these data to quantify how many different medications (defined as their simple generic equivalent) required PA by each plan, and how many of those medications required PA by 1, 2, 3, or all 4 insurance plans. Second, electronic health record data from the health system were queried for all prescription medication orders written during 2017 for patients age 18 years or older who were insured by 1 of the 4 plan types at the affiliated health insurance company with a pharmacy benefit. We stratified these orders into 4 groups based on which insurance type the patient had at the time of the prescription order. Within each group, we counted how many prescription orders had been written for all of the medications that had been listed as requiring PA by a given plan, and we generated a ranked list of the most frequently prescribed PA-requiring medications in each of the 4 plans. Note that because exceptions and discretion may be applied by providers during the actual PA process, we did not have data to ascertain whether the prescription orders definitely triggered the PA process, only that they might have per the insurance company’s medication lists and policy. The study was approved by an institutional review board. Results In 2017, the 4 insurance plan types differed in the number of medications (defined by their simple generic equivalent) for which PA was required. The commercial insurance plan listed 271 medications as needing PA; the marketplace plan, 440; the Medicaid plan, 72; and the Medicare plan, 272. Because of overlap between plans, these numbers resulted in a total of 600 medications requiring PA by at least 1 plan type. We observed that the majority of the medications requiring some level of PA were not required to have PA uniformly across all 4 plan types. Only 32 medications (5% of the 600) required PA by all 4 insurance types ( appendix), and there were only 151 medications (25% of the 600) for which PA was required by at least 3 of the 4 insurance plan types. During 2017, there were a total of 691,457 prescription orders (for any medication) documented in the electronic health record by prescribers in the outpatient setting for 114,159 health plan members meeting the inclusion criteria. Of those orders, 31,631 (5%) were written for one of the 600 medications noted above that required PA by at least 1 of the insurance plans. When taking into consideration the member plan at the time of each order, there were 12,540 orders (for 6,642 members) for which PA should have been triggered, based on the medication lists; this accounted for 1.8% (or approximately 1 in 56) of all orders written by prescribers in the outpatient setting for health plan members in 2017. The most commonly prescribed pharmaceutical classes for which PA was required by at least 1 plan were antihyperlipidemics (22% of orders potentially requiring PA), narcotic analgesics (13%), hypnotics (12%), antidiabetic medications (9%), and antidepressants (9%). Table 1 details these most commonly prescribed medications by insurance type, showing that the most frequently prescribed PA-requiring medications for each plan type were sildenafil (commercial, 16.9% of orders), oxycodone ER (marketplace, 48.1% of orders), diclofenac gel (Medicaid, 26.5% of orders) and simvastatin (Medicare, 33.4% of orders). Table 1. Top 10 Most-Prescribed Medications Requiring Prior Authorization, by Insurance Plan Typea,b Rank . Commercial (n = 2,689 Orders) . . Marketplace (n = 54 Orders) . . Medicaid (n = 1,438 Orders) . . Medicare (n = 8,300 Orders) . . . Medication . No. (%) . Medication . No. (%) . Medication . No. (%) . Medication . No. (%) . 1 Sildenafil 455 (16.9) Oxycodone ER 26 (48.1) Diclofenac gel 381 (26.5) Simvastatin 2,776 (33.4) 2 Diclofenac gel 326 (12.1) Sildenafil 6 (11.1) Celecoxib 214 (14.9) Zolpidem tartrate 1,533 (18.5) 3 Modafinil 315 (11.7) Empagliflozin 5 (9.3) Fluticasone/salmeterol 179 (12.4) Oxycodone ER 990 (11.9) 4 Oxycodone ER 225 (8.4) Modafinil 4 (7.4) Glyburide 159 (11.1) Amitriptyline 984 (11.9) 5 Sitagliptin 192 (7.1) Armodafinil 2 (3.7) Buprenorphine 116 (8.1) Esomeprazole magnesium 413 (5.0) 6 Esomeprazole magnesium 177 (6.6) Diclofenac gel 2 (3.7) Buprenorphine/naloxone 92 (6.4) Sildenafil 346 (4.2) 7 Buprenorphine/naloxone 91 (3.4) Tolterodine ER 2 (3.7) Atomoxetine 63 (4.4) Glyburide 194 (2.3) 8 Liraglutide 89 (3.3) Esomeprazole magnesium 1 (1.9) Adalimumab 57 (4.0) Liraglutide 107 (1.3) 9 Dexmethylphenidate 84 (3.1) Lansoprazole 1 (1.9) Empagliflozin 55 (3.8) Clarithromycin 89 (1.1) 10 Tacrolimus ointment 72 (2.7) Liraglutide 1 (1.9) Canagliflozin 30 (2.1) Modafinil 87 (1.0) Rank . Commercial (n = 2,689 Orders) . . Marketplace (n = 54 Orders) . . Medicaid (n = 1,438 Orders) . . Medicare (n = 8,300 Orders) . . . Medication . No. (%) . Medication . No. (%) . Medication . No. (%) . Medication . No. (%) . 1 Sildenafil 455 (16.9) Oxycodone ER 26 (48.1) Diclofenac gel 381 (26.5) Simvastatin 2,776 (33.4) 2 Diclofenac gel 326 (12.1) Sildenafil 6 (11.1) Celecoxib 214 (14.9) Zolpidem tartrate 1,533 (18.5) 3 Modafinil 315 (11.7) Empagliflozin 5 (9.3) Fluticasone/salmeterol 179 (12.4) Oxycodone ER 990 (11.9) 4 Oxycodone ER 225 (8.4) Modafinil 4 (7.4) Glyburide 159 (11.1) Amitriptyline 984 (11.9) 5 Sitagliptin 192 (7.1) Armodafinil 2 (3.7) Buprenorphine 116 (8.1) Esomeprazole magnesium 413 (5.0) 6 Esomeprazole magnesium 177 (6.6) Diclofenac gel 2 (3.7) Buprenorphine/naloxone 92 (6.4) Sildenafil 346 (4.2) 7 Buprenorphine/naloxone 91 (3.4) Tolterodine ER 2 (3.7) Atomoxetine 63 (4.4) Glyburide 194 (2.3) 8 Liraglutide 89 (3.3) Esomeprazole magnesium 1 (1.9) Adalimumab 57 (4.0) Liraglutide 107 (1.3) 9 Dexmethylphenidate 84 (3.1) Lansoprazole 1 (1.9) Empagliflozin 55 (3.8) Clarithromycin 89 (1.1) 10 Tacrolimus ointment 72 (2.7) Liraglutide 1 (1.9) Canagliflozin 30 (2.1) Modafinil 87 (1.0) Abbreviation: ER, extended release. aMedication counts represent number of prescription orders written for health plan members during the study timeframe. Percentages represent proportion of all prescription orders written for medications requiring prior authorization by member plans. bPrior authorizations are regulated by state and federal agencies and may be implemented to prevent drug-drug interactions or due to age-based prescribing restrictions. Open in new tab Table 1. Top 10 Most-Prescribed Medications Requiring Prior Authorization, by Insurance Plan Typea,b Rank . Commercial (n = 2,689 Orders) . . Marketplace (n = 54 Orders) . . Medicaid (n = 1,438 Orders) . . Medicare (n = 8,300 Orders) . . . Medication . No. (%) . Medication . No. (%) . Medication . No. (%) . Medication . No. (%) . 1 Sildenafil 455 (16.9) Oxycodone ER 26 (48.1) Diclofenac gel 381 (26.5) Simvastatin 2,776 (33.4) 2 Diclofenac gel 326 (12.1) Sildenafil 6 (11.1) Celecoxib 214 (14.9) Zolpidem tartrate 1,533 (18.5) 3 Modafinil 315 (11.7) Empagliflozin 5 (9.3) Fluticasone/salmeterol 179 (12.4) Oxycodone ER 990 (11.9) 4 Oxycodone ER 225 (8.4) Modafinil 4 (7.4) Glyburide 159 (11.1) Amitriptyline 984 (11.9) 5 Sitagliptin 192 (7.1) Armodafinil 2 (3.7) Buprenorphine 116 (8.1) Esomeprazole magnesium 413 (5.0) 6 Esomeprazole magnesium 177 (6.6) Diclofenac gel 2 (3.7) Buprenorphine/naloxone 92 (6.4) Sildenafil 346 (4.2) 7 Buprenorphine/naloxone 91 (3.4) Tolterodine ER 2 (3.7) Atomoxetine 63 (4.4) Glyburide 194 (2.3) 8 Liraglutide 89 (3.3) Esomeprazole magnesium 1 (1.9) Adalimumab 57 (4.0) Liraglutide 107 (1.3) 9 Dexmethylphenidate 84 (3.1) Lansoprazole 1 (1.9) Empagliflozin 55 (3.8) Clarithromycin 89 (1.1) 10 Tacrolimus ointment 72 (2.7) Liraglutide 1 (1.9) Canagliflozin 30 (2.1) Modafinil 87 (1.0) Rank . Commercial (n = 2,689 Orders) . . Marketplace (n = 54 Orders) . . Medicaid (n = 1,438 Orders) . . Medicare (n = 8,300 Orders) . . . Medication . No. (%) . Medication . No. (%) . Medication . No. (%) . Medication . No. (%) . 1 Sildenafil 455 (16.9) Oxycodone ER 26 (48.1) Diclofenac gel 381 (26.5) Simvastatin 2,776 (33.4) 2 Diclofenac gel 326 (12.1) Sildenafil 6 (11.1) Celecoxib 214 (14.9) Zolpidem tartrate 1,533 (18.5) 3 Modafinil 315 (11.7) Empagliflozin 5 (9.3) Fluticasone/salmeterol 179 (12.4) Oxycodone ER 990 (11.9) 4 Oxycodone ER 225 (8.4) Modafinil 4 (7.4) Glyburide 159 (11.1) Amitriptyline 984 (11.9) 5 Sitagliptin 192 (7.1) Armodafinil 2 (3.7) Buprenorphine 116 (8.1) Esomeprazole magnesium 413 (5.0) 6 Esomeprazole magnesium 177 (6.6) Diclofenac gel 2 (3.7) Buprenorphine/naloxone 92 (6.4) Sildenafil 346 (4.2) 7 Buprenorphine/naloxone 91 (3.4) Tolterodine ER 2 (3.7) Atomoxetine 63 (4.4) Glyburide 194 (2.3) 8 Liraglutide 89 (3.3) Esomeprazole magnesium 1 (1.9) Adalimumab 57 (4.0) Liraglutide 107 (1.3) 9 Dexmethylphenidate 84 (3.1) Lansoprazole 1 (1.9) Empagliflozin 55 (3.8) Clarithromycin 89 (1.1) 10 Tacrolimus ointment 72 (2.7) Liraglutide 1 (1.9) Canagliflozin 30 (2.1) Modafinil 87 (1.0) Abbreviation: ER, extended release. aMedication counts represent number of prescription orders written for health plan members during the study timeframe. Percentages represent proportion of all prescription orders written for medications requiring prior authorization by member plans. bPrior authorizations are regulated by state and federal agencies and may be implemented to prevent drug-drug interactions or due to age-based prescribing restrictions. Open in new tab Discussion We observed relatively high variation among 4 plans within a health insurance company, with only 5% (32 of 600) of the medications requiring PA by all 4 of the plans. We also found that in 2017, approximately 1 out of 56 prescriptions written for patients (at the health system affiliated with the insurance company) were for medications that may have required PA, depending on the member’s plan and clinical parameters. The percentage of medications requiring PA is small, but even for those few medications prescribers are unaware of when one will require PA.6 The variation in PA requirements within different plans of a health insurance payor that was observed in our study is consistent with previous literature.3,4 It is important to note that some insurance products can be restricted by state or federal regulations that every insurance company has to comply with and implement (eg, those for opioid-containing products).7 The reason for this variation is multifactorial and attributed to issues such as government regulations and patient populations served.3-5 Often this variation is unavoidable due to the different populations each plan serves. One example is the medication zolpidem, which requires PA when prescribed for an individual with Medicare because it is considered a high-risk medication in the elderly but may not be restricted for other insurance products that cater to younger patient populations. Additionally, variation alone does not tell the full story, as some insurance products may require fewer PAs but have a more restrictive formulary to manage prescription benefits. There are a multitude of reasons for implementing the PA process. A main reason is to optimize patient care by ensuring the safety and effectiveness of medications prescribed. By implementing this safeguard mechanism, health insurance companies can suggest that a provider use a certain medication to discourage and regulate the cost of expensive pharmaceuticals and medical procedures. Four of the most commonly prescribed pharmaceutical classes (the analgesic-narcotic, antidiabetic, antidepressant, and antihyperlipidemic classes) for which the health insurance plan required PA were in the top 15 classes based on overall per member per month spend, according to a 2018 medication trend report from Express Scripts.8 While clinical considerations often drive PA requirements, cost is also a potential factor. Systems that do not pass administrative costs on to patients due to the increasing number of individuals requiring these medications and the amount of medications requiring PA need to be developed.9,10 Most clinicians care for patients with different insurances and different PA requirements. Determining at the point of care whether or not a medication being prescribed will require PA should, ideally, be part of the decision-making process.5 In our study, we found that even for patients insured by a particular company, 600 different medications could potentially require PA. Providers do not generally have an efficient way of knowing at the point of care which medications require PA, which has been shown in other work to contribute to provider frustration with the entire process.6 In 2011, the American Medical Association requested more transparency around the PA process and called for new and innovative solutions to help ease the burden of the process for both patients and clinicians.11 Since then, the National Council for Prescription Drug Programs approved a standardized electronic PA process for PA requests.12 Implementation of electronic PA has been slow and challenging.13 Some potential solutions include enabling providers to know which medications require PA at the time of prescribing and utilization of electronic health records to complete PA requests.14 However, in 2015 only 18% of commercial health plans and providers had implemented a fully electronic method for submitting PAs.11,15 Alternative solutions include implementation of a real-time decision support tool to answer PA requests.16 Further research on and implementation of tools that can help improve transparency about medications requiring PA and PA criteria are needed. The primary limitation of the study was that it examined a single health insurance company and prescriptions written within a single integrated health delivery system. Future work should compare these results with those of other systems and health insurance plans, because by examining this variation at other health insurance companies and systems we would be better able to describe the variation that could occur for consumers and healthcare providers. We also focused on the payor policy (ie, which medications required PA) and the overall volume of prescriptions written for listed medications over 1 year for the insured population, but we did not document how many orders triggered a PA request, how many PAs were approved, or the time to approval for PAs. It is important to recognize that our cross-sectional study provided an overestimate of the number of PAs in 2017 because it described all prescription orders in a 1-year timeframe but did not determine whether or not these orders prompted the PA process due to clinical criteria or whether they were reauthorizations. In addition, when only studying the health insurance plan for a particular year, it is possible that certain regulations implemented in that year (eg, regulations in some insurance products requiring PA for opioid-containing products) could have led to increased variation. Further, we did not describe the extent of the PA requirements (eg, whether or not they focused on drug-drug interactions, age restrictions, or other factors). For the top 10 list of medications provided, we did not identify those bound by certain regulatory requirements, clinical initiatives, or reauthorizations, which could have influenced the percentages of the medications listed. Additionally, we included patients with health insurance at any time during 2017 and assumed that they could have been impacted by a prescription order for 1 of the PA-requiring medications, despite the fact that we recognize that patients could have started and stopped their pharmacy coverage at any time in the year. Conclusion Health insurance companies use various methods, including PA, to promote safe and effective medication use and contain costs. Variation in medications requiring PA exists between health insurance products but is often unavoidable due to regulations. While relatively few medications require PA, further research is needed to understand the implications of this variation on clinical practice. Disclosures This work was performed with funding from the Pennsylvania Department of Health (CURE: SAP # 4100072547), which did not participate in any portion of the study. The authors have declared no potential conflicts of interest. References 1. Phillips C . 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Morra D , Nicholson S , Levinson W et al. US physician practices versus canadians: spending nearly four times as much money interacting with payers . Health Aff (Millwood). 2011 ; 30 ( 8 ): 1443 - 50 . Google Scholar Crossref Search ADS PubMed WorldCat 10. Sakowski JA , Kahn JG , Kronick RG et al. Peering into the black box: billing and insurance activities in a medical group . Health Aff (Millwood). 2009 ; 28 ( 4 ): w544 - 54 . Google Scholar Crossref Search ADS PubMed WorldCat 11. American Medical Association. Standardization of prior authorization process for medical services white paper. http://www.amaassn.org/resources/doc/psa/standardization-prior-auth-whitepaper.pdf. Published 2011 . Accessed February 28, 2019 . 12. Proceedings of the AMCP Partnership Forum: NCPDP electronic prior authorization standards—building a managed care implementation plan . J Manag Care Spec Pharm . 2015 ; 21 ( 7 ): 545 - 50 . PubMed OpenURL Placeholder Text WorldCat 13. Silversmith J , Topor L . Electronic prior authorization is here: what you need to know about it . Minn Med. 2016 ; 99 ( 2 ): 44 - 6 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 14. Epling JW , Mader EM , Morley CP . Practice characteristics and prior authorization costs: secondary analysis of data collected by SALT-net in 9 central new york primary care practices . BMC Health Serv Res. 2014 ; 14 : 109 . Google Scholar Crossref Search ADS PubMed WorldCat 15. Athenainsight . Infographic: Prior authorizations, explained . https://www.athenahealth.com/insight/infographic-prior-authorizations-explained. Accessed August 29, 2018 . 16. Newcomer LN , Weininger R , Carlson RW . Transforming prior authorization to decision support . J Oncol Pract. 2017 ; 13 ( 1 ): e57 - 61 . Google Scholar Crossref Search ADS PubMed WorldCat Appendix—Medications requiring prior authorization by all 4 evaluated insurance plans Abatacept, abiraterone acetate, afatinib dimaleate, alectinib hydrochloride (HCL), alirocumab, ambrisentan, asfotase alfa, axitinib, bosutinib, buprenorphine HCL, buprenorphine HCL/naloxone HCL, cabozantinib s-malate, canagliflozin, ceritinib, certolizumab pegol, cholic acid, cobimetinib fumarate, crizotinib, dabrafenib mesylate, dalfampridine, darbepoetin alfa, dasatinib, dornase alfa, empagliflozin, empagliflozin/metformin HCL, epoetin alfa, erlotinib HCL, etanercept, everolimus, evolocumab, fentanyl citrate, gefitinib © American Society of Health-System Pharmacists 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Medications requiring prior authorization across health insurance plans
JO - American Journal of Health-System Pharmacy
DO - 10.1093/ajhp/zxaa031
DA - 2020-04-01
UR - https://www.deepdyve.com/lp/oxford-university-press/medications-requiring-prior-authorization-across-health-insurance-f9CBZSQ8xM
DP - DeepDyve
ER -