Originally published in The Tennessean, July 2024
Nationwide, prescription drugs are the most costly and commonly used health plan benefit. Last year, BlueCross spent more than $3 billion on medications for our members.
Every one of those dollars came from a BlueCross customer, so it’s important for us to use our resources wisely. Prior authorization (PA) is a tool we use to help manage these costs. Even more importantly, they’re a safety measure.
Our goal is to ensure our members have the right drug, the right dose, for the right person, and at the right place.
We take a full picture of a member’s condition and unique experience into consideration when we make decisions — at a policy and individual level. That means weighing cost, efficacy and possible drug interactions against the overall benefits of a prescription medication.
Some drugs, if prescribed incorrectly, have the potential to cause harm. PAs help cut down on what’s called off-label usage, where doctors prescribe drugs for conditions that the Food and Drug Administration (FDA) hasn’t reviewed and approved.
More than 300,000 prior authorization requests are made each year by health care providers prescribing certain medications for BlueCross members. And by monitoring and approving these prescriptions, we keep people safe and help keep premiums affordable for all our members.
Understanding our role
Our focus on value is just one aspect of how we’re working to ease the burden on our members.
We use PAs if there’s a more affordable drug that’s been studied and found to have equal efficacy to a more expensive option. On the flip side, a costly medication can keep people out of the emergency room and out of the hospital — in that way, we can actually save money by covering a medication that’s more expensive.
We’ve also implemented new technology making the PA process as simple and fast as possible so that providers can submit authorizations electronically. Those electronic submissions receive faster turnaround times, and providers can track the status of each prior authorization on a dashboard in real-time.
Sometimes our members and providers don’t have to be involved in the PA process whatsoever. Claims information can allow a prescription to process without a “hard stop” at the pharmacy. For example, if someone has Type 2 diabetes and a medical claim related to it, then certain diabetes medications that require a PA will process without any additional information. We call these “smart PAs.”
We’ve seen the value in streamlining the PA process, moving it from an external pharmacy benefits company to our own in-house teams of credentialed specialists. This applies to medications usually taken by members themselves, as well as those administered at doctors’ offices or hospitals. It reduces steps for providers, improves turnaround time and further reduces costs for our members.
Staying up to date
We realize the information on medications can change. That’s why we constantly evaluate clinical studies, as a drug may get a new indication — the use of a drug for treating a particular disease — and we meet weekly to ensure we evaluate any new indications. Alternatively, a drug may be removed from the market because it was found to be ineffective or, in some cases, unsafe.
There’s a misconception that prior authorizations (PAs) only exist to deny health care and treatment.
At BlueCross, the majority of PA requests are approved. When taken properly, drugs can improve and save lives. But improper drug use is dangerous — adverse reactions can lead to hospitalization and death.
For us, avoiding that human cost makes prior authorizations worth the effort.
Dr. Tate oversees all aspects of the pharmacy management program and provides strategic direction for our teams charged with helping BlueCross members improve their health outcomes.