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Refocusing Medication Prior Authorization on Its Intended Purpose

Educational Objective
To understand the negative impacts on patient care and administrative costs of prior authorization in Dermatology
1 Credit CME

During the 1980s, prospective utilization review programs deployed by US health plans focused on screening the appropriateness of hospital admissions and high-cost procedures. As prescription drug coverage became more widespread and spending on pharmaceuticals increased, commercial and public insurers expanded utilization management to include medication prior authorization, quantity and dosage limits, and step therapy requirements. Applied in concert with restricted formularies and tiered patient cost sharing, these measures were initially directed during the 1990s and early 2000s at a narrow set of newer, high-cost drugs that insurers judged to offer limited benefit or higher risk over existing, less expensive alternatives.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Jack S. Resneck Jr, MD, Philip R. Lee Institute for Health Policy Studies and Department of Dermatology, School of Medicine, University of California, 1701 Divisadero St, PO Box 0316, San Francisco, CA 94143 (resneckj@derm.ucsf.edu).

Published Online: February 3, 2020. doi:10.1001/jama.2019.21428

Conflict of Interest Disclosures: Dr Resneck serves as immediate past chair of the Board of Trustees of the American Medical Association. Dr Resneck also serves on the board of directors of the National Quality Forum. Dr Resneck reported serving as an expert witness within the last 3 years; however, none of the cases was focused on the topic of prior authorization.

Disclaimer: The views expressed are those of the author and do not necessarily represent the views of the American Medical Association.

References
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2.
Milliman Inc. Evolution of the use of restrictions in commercial formularies. https://www.milliman.com/uploadedFiles/insight/2016/evolution-restrictions-commercial-formularies.pdf. Accessed November 29, 2019.
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American Medical Association. 2018 AMA prior authorization physician survey. https://www.ama-assn.org/system/files/2019-02/prior-auth-2018.pdf. Accessed November 29, 2019.
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CoverMyMeds. Prepare for a seasonal increase in prior authorization requests. https://www.covermymeds.com/main/insights/articles/prepare-for-a-seasonal-increase-in-pa-requests/. Accessed November 29, 2019.
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Office of Inspector General. US Department of Health and Human Services. Some Medicare Part D beneficiaries face avoidable extra steps that can delay or prevent access to prescribed drugs. https://oig.hhs.gov/oei/reports/oei-09-16-00411.pdf. Accessed December 4, 2019.
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American Medical Association. Consensus statement on improving the prior authorization process. https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/arc-public/prior-authorization-consensus-statement.pdf. Accessed November 29, 2019.
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