• Typically a Provider’s Office is notified by a patients' pharmacy when your brand drug has been rejected. They are usually faxed a “Pharmacy Rejection Notice” that states the reason for the payer’s denial and recommends one or more substitutable options.
• The Provider’s Office is instructed to fax 1.) the "Rejection Notice" along with 2.) a "Tried Medications List” (TML) to our service. This typically takes less than 5 minutes of office staff time.
• Our PA Tech then places a phone call(s) to the patient’s health plan, speaks to the appropriate personnel and attempts to secure an approval for the brand medication prescribed. This usually involves sharing the diagnosis and the other drugs the patient has already trialed.
• If approved, our service contacts the Provider’s office to relay that the medication may now be dispensed. If not approved, PA advises by fax the medications still necessary for the patient to try before approval.
• As an additional service, our PA Techs can automatically transmit your Co-Pay Coupon simultaneously to both the Provider’s Office and to the pharmacy where the script was originally rejected. This helps ensure fulfillment as the out-of-pocket burden to the patient is reduced.
• It is the list of drugs that the patient has tried that are in the same class of drug being prior authorized. It must be initialed at the bottom by a member of the referring Provider’s Office indicating that the drugs "checked" above have been previously tried by the patient. Again, this information is readily accessed by office staff in under 5 minutes.
• Priority Authorizations has a team of experienced PA Techs who call on behalf of the patients.
• In almost every case, we contact the plans by phone the same day we receive your request.
• Response times vary from plan to plan, but same day approvals are not uncommon.
1.) The pharmacy Rx Rejection Notice
2.) The "Tried Medications" checklist
• This service may be used for any drug in the therapeutic drug class specified in the PA/Medical provider office agreement.
1.) Importantly, WE control the PA request, not the Provider’s Office staff. We typically know the approval criteria for your drug better than the Health Plan or PBM technician with whom we are speaking.
2.) We know before we call (or electronically submit the PA request) whether or not the patient has met the approval criteria: this is not typically the case with the Provider’s Office staff.
3.) We have more “upside” in getting your drug’s PA Approval than the Office staff.
4.) Office staff like filling out 1 sheet (TML) and faxing it to us along with the Rejection Notice vs. waiting on hold to speak with insurance companies.
5.) They appreciate this lifted burden of doing PAs.
• No. If patients have not met the PA criteria, the request will not generally be approved. We can only share with the insurance plan the medications that the office or the patient indicates have been tried previously and in what time period.
• There is a 4-page agreement (Business Associates Agreement) for HIPAA purposes which also gives our PA Techs the right to represent their patients in our discussions with the insurance plans.
• No, it is completely free-of-charge to them.
• No, as long as their patients have tried the generally known medications necessary to fill the prior authorization criteria, there is no limit to the number of requests that they can initiate.
• The Provider’s Office contacts the patient when the approval has been secured by our PA Techs. We (can) also automatically send the Office and the Pharmacy where the original rejection occurred an electronic Co-Pay buy-down coupon to maximize fulfillment potential of the script.