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AMCP Develops Concepts for Effective Prior Authorization and Utilization Management Practices

Alexandria, Va., June 14, 2019 — The Academy of Managed Care Pharmacy (AMCP) has developed nine concepts around the effective use of prior authorization that managed care organizations can follow to ensure that PA processes are timely, transparent, collaborative and supportive of patient-centered care.

Prior authorization is an integral tool in the management of drug formularies, which are overseen by managed care organizations (MCOs) such as health plans and pharmacy benefit management companies. Drugs that require a prior authorization are not approved for payment unless certain evidence-based conditions for appropriate use are met.

“The practice helps improve patient outcomes by encouraging the use of therapies that have established evidence of efficacy and safety,” says AMCP CEO Susan A. Cantrell, RPh, CAE. “Evidence-based prior authorization programs also play a crucial role in reducing waste and error, along with unnecessary medication use and costs. PAs allow us to remain good stewards of our health care resources.”

While PAs have been used successfully for decades, many agree there is room for improvement in the PA process. The AMCP Professional Practice Committee recently developed best practices around nine specific concepts to support more timely, efficient and collaborative PA processes.

The concepts, published in the June 2019 issue of AMCP’s Journal of Managed Care & Specialty Pharmacy, center on: (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) need for timeliness and avoiding disruptions in therapy; and (9) cost-effectiveness and value.

Among its recommendations, the concepts urge MCOs to: use health IT solutions to reduce paperwork and waste, and improve the patient and clinician experience; collaborate and communicate clearly with providers throughout the PA process; provide advanced notice of formulary changes to the provider and patient; avoid broad or inflexible PA requirements for drug therapies commonly used as part of emergency care; and allow for timely PA approval for medically necessary exceptions and for timely handling of denial appeals.

The Professional Practice Committee also notes that MCOs have the responsibility and opportunity to incorporate clinical and technology advancements into these processes, with a constant goal of improving health outcomes and cost-effectiveness. AMCP supports all concepts to ensure patients receive appropriate and timely access to drugs, devices, and other therapeutic agents. Read the concepts at http://bit.ly/2IdCkXz.