Specialty Drugs – Why a PreAuthorization is Needed

Pinnacle Claims Management Specialty Drugs

As we discussed in an earlier article this year on specialty drugs, these type of medications play an important role in treating employees with persistent and complex health conditions such as oncology, hepatitis C, HIV, MS, Parkinson’s and rheumatoid arthritis. While we have always required a preauthorization, or advanced approval, for specialty drugs, the number of employees using these medications is increasing and you may be getting questions on why a preauthorization is necessary.  

“Getting a preauthorization by our clinical team, which consists of pharmacists and other health care professionals, is an important step to ensuring quality of care for our participants,” explains PCMI President David Zanze.  Before the clinical team can preauthorize a specialty medication, they look for:  

Off-label use. While a prescribing doctor may come up with their own combination of drugs to help treat a patient’s specific illness, our clinical team does not consider this a safe route to take and one they will typically not approve. This “medical cocktail” created by the doctor is what the medical industry refers to as an off-label drug. This means that the biologic medication’s intended use and/or dosage prescribed has not been approved by the US Food and Drug Administration. Without sufficient trials, this off-label drug may have severe negative consequences for the patient. 

Medical necessity. Our clinical team reviews the prescription to make sure that it is medically necessary, which means that the treatment advised meets a generally accepted standard of medical practice based on credible scientific evidence recognized by the medical community. In other words, information that is included in peer reviews and published in medical journals for example. 

Clinically appropriate. The board ensures that the medication’s type, frequency and duration are considered the most effective level of treatment for the patient. In many cases, they will advise a smaller dose of medication to be prescribed to the patient to make sure there are no side effects before authorizing a 30-day or more dosage. 

Cost-effective choice. To keep pharmacy costs down for the employer, it’s important for the board to ensure that the prescribed medication does not have a less costly alternative that can produce the same therapeutic or diagnostic results for the patient. 


Obtaining Pre-authorization is Simple

To get preauthorization, the employee’s prescribing doctor needs to contact PCMI’s customer service number at (800) 649-9121. The customer service representative will contact a clinical team member who will do the review and then contact the doctor directly with their approval or an alternative. The patient will then be able to purchase their medication as they normally would.

A clinical staff member will also follow up with the patient to see how the medication is working for them and if there are any negative side effects. It is important to convey to your employees that they be honest about how well the medication is working so that an alternative medication can be prescribed if necessary.