Medication prior authorizations (PAs) are a vexing part of practice for family medicine physicians and their office staff. PAs are often not based on the most recent clinical guidelines or scientific evidence and have increasingly become a barrier to timely patient-centered care.¹ PAs are equally exasperating for patients, who anticipate that the prescriptions you write will be filled without significant delay or inordinate expense. There is no clear evidence that PA requirements improve quality or patient-centered outcomes. PA has been shown to decrease the use of targeted therapies and the costs associated with them;^2,3 however, that does not translate to improved clinical outcomes. Prescribing decisions should be guided by the physician's judgment, patient understanding, and clinical evidence, rather than driven by an insurance algorithm.

Although multiple facets of patient care (medications, diagnostic imaging, durable medical equipment, surgical procedures, and inpatient hospital care) can trigger the PA process, this article will deal only with medication PAs. We will describe several steps family physicians can take to reduce medication PAs.

PRESCRIBE GENERIC MEDICATIONS WHENEVER POSSIBLE

Prescribing generic medications not only helps you avoid PA but also ensures that your patients secure the lowest copayment when they fill their prescriptions. Choose a generic medication within the same class as the one triggering the PA to eliminate the process and secure a quick victory for your team. The cost savings of generics can accumulate, especially for patients on multiple medications. If patients insist on a branded medication and you think it may not be medically necessary, explain that the time spent on PA detracts from the time available for direct care, and the use of generics reduces their copay and overall costs. When branded medications are necessary, having documented evidence of previous attempts to use generic alternatives for the patient is crucial.

In some circumstances, even prescribing a generic medication will trigger a PA. This can occur with expensive generics or medications on the Beers List for patients age 65 and over (discussed below).

BOOKMARK YOUR STATE'S MEDICAID PHARMACY WEB PAGE

If you have patients with Medicaid, be aware that a formulary or preferred drug list is available on your state program's website. You can use this resource to identify which medications will avoid triggering PAs. The pharmacy page will include links to the most recent formulary, PA criteria, participating pharmacy networks, as well as updates on drug safety and specialty medications. Awareness of this resource is particularly important to assist patients who do not have the resources to understand or access it for themselves.

Making patients aware of this resource can help empower them to better understand and apply their formulary rules. For example, if they see for themselves that a medication they've heard about on TV or social media isn't on their formulary, they'll better understand their choices — pay more for the branded drug or use a generic. (We discuss more ideas for empowering patients later in the article.)

DESIGNATE ONE PERSON OR TEAM TO LEAD THE PA PROCESS FOR YOUR OFFICE

PA tasks can feel daunting, especially when squeezed in between patient encounters. Consider identifying a detail-oriented staff member who thrives on such tasks to champion PA efforts for your office, or form a small collaborative team to efficiently manage this process. Allocate specific blocks of time for PA instead of relegating this work to interrupted minutes between patient encounters. This can decrease stress and improve accuracy. The team can track the circumstances that trigger PAs and can maintain a logbook with essential details such as patient names, medications, request dates, insurance information, and reasons for authorizations/denials when possible. Though not exhaustive, this logbook provides valuable insights into time, costs, and trends for an improvement cycle. As the champion or team becomes more adept, they can offer process-improvement ideas to ultimately reduce the administrative burden for everyone. They can also equip office staff to help empower patient participation in the PA process.

ASSESS YOUR OFFICE'S PA PRACTICES AND DETERMINE HOW TO IMPROVE EFFICIENCY

According to a survey from the American Medical Association (AMA), clinicians and staff spend 12 hours per week on PAs, completing 43 PAs per physician.¹ A 2019 study found that, on average, each manual PA costs an office $11.⁴ And a 2009 study found that physicians and administrators spend approximately 142 hours annually dealing with health plans, resulting in an annual cost of $31 billion to physician practices, or $68,274 per physician.⁵ Thus, efforts to reduce PAs and streamline the process can be highly valuable, providing significant time savings, financial savings, and stress relief for your office.

Ideas for improving your office process can come from a regular review involving a clinician and your PA champion or team. Consider the following action steps.

Identify alternatives to medications that regularly trigger PA or denials. Examples include the following:

• Duloxetine consistently triggers PA in our practice and is often denied even after going through the PA process. This generic medication is costly and unaffordable for many patients to purchase out of pocket, so we inform patients of this issue and advise them to use prescription discount cards from programs such as GoodRx, Optum Perks, or SingleCare, which they can obtain online before visiting the pharmacy of their choice. When you think a patient will encounter a PA and denial, advise them to take a prescription discount card to the pharmacy so treatment is not delayed.

• Lidocaine patches prescribed for pain unrelated to postherpetic neuralgia are not covered by any of our insurance plans despite going through the PA process. The most cost-effective alternative we have found is to advise patients of the option to purchase over-the-counter Salonpas (60 patches for around $10). Recommend over-the-counter alternatives when you suspect a prescribed medication will be denied.

• Proton pump inhibitors (PPIs) prescribed for the treatment of gastroesophageal reflux disease (GERD) beyond eight weeks are often denied. In such instances, we suggest over-the-counter alternatives such as omeprazole or esomeprazole. Omeprazole 20 mg is available for $10–15 per month, but with a discount card, a 90-day supply is $12–15. Recommend inexpensive over-the-counter alternatives when patient treatment has the potential to be disrupted by a PA and denial.

• Fluticasone/salmeterol inhaler is available as several brands — Advair Diskus or HFA, Wixela Inhub, and AirDuo Digihaler or RespiClick. The most cost-effective option we've found is Airduo RespiClick using a GoodRx savings card ($44 at the time of publication; use of this savings card is independent of the patient's insurance). Manufacturer coupons are sometimes available for these expensive products, but only qualifying patients with commercial insurance can use them. Identify the least expensive member of a drug class and empower patients to use a prescription discount card to obtain the medication when you expect PA and denial. Prescription discount cards can help patients begin treatment while you are awaiting the PA process.

Identify clinicians who overutilize staff time for PAs. Offer them education about the PA process or provide specific recommendations on medication management that could eliminate the necessity of PA.

Recognize that a denial may occur when clinicians prescribe a medication without evidence of clinical efficacy. Examples include topical acyclovir for herpes simplex virus (HSV1), crisaborole for atopic dermatitis, and clotrimazole/beta-methasone for any indication. Inform the prescriber about the denial, and encourage use of an evidence-based treatment.

Compile a list of prescription issues that prompt PA. Examples include prescribing the incorrect quantity, strength (e.g., two 10 mg tablets of citalopram instead of one 20 mg tablet), or frequency (e.g., amlodipine 2.5 mg twice daily instead of 5 mg daily), and prescribing early refills. Share these common errors with your group (and informatics team if you have one) so you can implement changes to your electronic health record (EHR) prescription screen to prevent unnecessary PAs.

LEVERAGE YOUR EHR'S FORMULARY DATA, BUT BE AWARE OF POTENTIAL INACCURACIES

Clinicians often assume that if their EHR indicates a medication is covered by a patient's insurance plan, then it will be covered. However, EHR formulary data can be inaccurate up to 20% of the time.⁶ This inaccuracy most commonly stems from two factors.

First, insurance companies often use different formularies for each of their plans and make frequent changes throughout the year, so each formulary's information must be entered into the EHR and updated regularly to ensure accuracy. This task would be unfeasible for individual practices, so most EHRs obtain the information from a formulary data vendor. Collaborating with your informatics team to assess and potentially switch formulary data vendors can help ensure that more precise formulary data is available at the point of prescribing.

Second, even if your EHR's formulary data is up to date, the patient's insurance data may not be. Patients frequently change insurance plans, and if their prescription insurance information is not current, the EHR will reference the incorrect formulary.

The bottom line is that clinicians and staff should do what they can to ensure up-to-date data in their EHR, but it's a moving target. Becoming familiar with the patient's specific formulary is ultimately the patient or caregiver's responsibility (discussed below).

EXPECT BEERS LIST MEDICATIONS TO TRIGGER PA FOR PATIENTS AGE 65 AND OVER

The American Geriatrics Society has compiled a list (referred to as the Beers List) of medications deemed “potentially inappropriate” for individuals age 65 and older. The organization stresses the importance of thoughtfully applying the list to support shared clinical decision-making rather than supplant it.⁷ Insurance companies often deny coverage for medications on this list for patients in this age group, even when you follow PA processes. Examples include warfarin, sulfonylureas, tricyclics, PPIs, nitrofurantoin, long-term non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxers, and oral/topical estrogens.

However, medications on this list may be appropriate in certain instances after shared clinical decision-making with the patient. Examples may include low-dose amitriptyline for interstitial cystitis, a short course of nitrofurantoin for a urinary tract infection (UTI) in an otherwise healthy female, or estrogen for a low-risk female. To help your patients obtain these medications without the hassle of PA or the risk of denial, encourage them to be proactive at the pharmacy and take the following steps:

• Patients should verify at the pharmacy whether the medication is covered under their insurance plan. If it is covered, they can proceed with the usual filling process.

• If the medication is not covered, patients should talk with the pharmacist about their options before the insurer issues a denial. Depending on the price, patients may choose to pay out of pocket or use a prescription discount card.

• Patients should understand that they may need to repeat this process yearly or sometimes with each refill.

EMPOWER PATIENTS TO TAKE AN ACTIVE ROLE IN OBTAINING THEIR MEDICATIONS

Many patients express frustration when navigating their formulary and the PA process. Although practices can assist patients in navigating these issues, ultimately it's their insurance and their responsibility to manage. Patients who understand this and comprehend the process tend to be more appreciative of your team's assistance and more understanding during delays and changes. Educating and empowering patients to actively participate in the process can transform the dynamics of interactions related to PAs and denials.

This shift also involves you and your staff using clear language. Statements like “your insurance plan will not cover this medication” can guide patients to direct their frustrations appropriately and recognize your role as their advocate. Encourage patients to bring a copy of their formulary or access it digitally during office visits to enhance their understanding of coverage and facilitate shared decision-making for treatment plans. The sheer number of formularies and the endless changes in formulary information make it untenable for even the most attentive clinician or staff member to maintain accurate prescribing data on all patients. This leads to an important decision in how you practice. Will you educate and encourage your patients to understand their formulary and apply it to prescribing as best they can, or will you shoulder the responsibility yourself? The latter option may be appropriate for patients who are ill-equipped to navigate the difficult waters of their formulary.

Additionally, provide your patients with savings cards (such as GoodRx) for use at the pharmacy, information about medication assistance programs (see NeedMeds.org), and details about retail pharmacy savings programs (such as Walmart's $4 prescription program). Providing educational handouts about the PA process and insurance restrictions can further support patient understanding (see an example here: https://familydoctor.org/health-insurance-understanding-covers/). Education is often a gradual process, so be patient as understanding grows.

If you suspect patients will experience a delay in obtaining their medications due to a PA, be sure to let them know. This simple action softens the blow at the pharmacy and assures patients that you are their teammate.

While prescription coverage details and copayments can often be unclear, they are crucial factors to consider as you strive to provide compassionate and affordable care. These costs can present significant barriers for patients. Research shows that higher out-of-pocket expenses are associated with increased prescription abandonment, with rates of 8% for costs up to $9.99, 21% for costs between $40 and $49.99, and 69% for costs exceeding $250.⁸ This highlights the importance of considering generic options and being mindful of medication costs and copays.

When discussing prescriptions with your patients, ask nonjudgmental questions about affordability and address concerns they may have. Show empathy and understanding about the financial challenges of healthcare, acknowledging that some patients may be forced to choose between copayments and essentials like groceries or monthly bills.

DOCUMENT YOUR INTERACTIONS WITH HEALTH PLANS AND ESTABLISH A POINT OF CONTACT FOR EACH CASE WHO CAN FOLLOW IT THROUGH TO COMPLETION

Repeatedly explaining the details of a patient's situation and the rationale for medication approval to multiple insurance representatives is frustrating and inefficient. To ensure a smoother process, try to identify one representative who can be your point of contact for each case. To establish this person's accountability, request their name, location, identification number, and contact details for future reference. Clearly communicate that if the matter is not resolved as discussed within the agreed-upon timeframe, you will reach out to them directly. Although speaking to a specific individual (versus the next available representative) may involve more hold time, it pays off when advocating for your patient during subsequent interactions. This person becomes your point of contact for all matters related to the specific case. Keep a log of calls, dates, specific instructions, and promises made.

The AMA and the American Academy of Family Physicians (AAFP) have expressed concern about adverse utilization-management decisions made by nonclinicians, especially those unfamiliar with the patient's care. This action is equivalent to the practice of medicine by the utilization-review entity.⁹ The AMA and AAFP have called for flexibility in the PA process, including timely overrides of step-therapy requirements, formulary exceptions, and rapid access to appeals, with decisions made by physicians who are at least as qualified as the prescribing physician.^9,10 Keep these principles in mind as you communicate with insurance companies and advocate for your patients.

WORK WITH YOUR GROUP OR HEALTH SYSTEM TO APPOINT A PA ADVOCATE TO SYSTEMATICALLY ADDRESS PA CHALLENGES

This individual, ideally an experienced physician, would work with each office's PA champion or team to analyze and share trends in medication denials and offer alternative pathways to obtain specific medications. This person could also offer education for peers who may not understand the PA process or who overutilize staff time for PAs. The PA advocate could also play a role in onboarding new prescribers, working with the informatics team to make sure formulary data is accurate in the EHR, and coordinating efforts with system pharmacists to streamline the PA process and enhance timely access to medications across the health care system.

Additionally, the PA advocate should stay informed about legislative and regulatory changes affecting the PA process and support prescribers in advocating for their patients. This person can also help implement insurance-specific and national initiatives aimed at improving medication access. One such regulatory change is the Centers for Medicare & Medicaid Services Interoperability and Prior Authorization Final Rule. It seeks to streamline the PA process by mandating that payers respond to urgent PA requests within 72 hours and standard requests within seven calendar days. Furthermore, it requires payers to provide a specific reason for denying PA requests and to publicly report certain PA metrics. Unfortunately, the compliance date for this rule is not until Jan. 1, 2026.¹¹

On the legislative front, the Improving Seniors' Timely Access to Care Act was reintroduced in Congress on June 12, 2024. While it only addresses PA in Medicare Advantage plans, it could pave the way for improvements in other plans. The bill would establish an electronic PA process, including real-time decisions for items and services that are routinely approved, and would encourage plans to adopt PA programs that adhere to evidence-based clinical guidelines in consultation with physicians, among other changes.¹²