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Right Care, Right Time, Right Cost: Why Prior Authorization Works

Driving down drug costs, fighting back against the opioid crisis, protecting patients from unnecessary treatment and helping to curtail rising health insurance costs may all seem unrelated, but they can be accomplished when patients, doctors and insurers work together through a process called “prior authorization.”

Prior authorization is a physician-involved process that  Blue Cross and other health insurers use to make sure our members receive the most effective, evidence-based care – and to make health care more affordable. At Blue Cross, this process saves our members and customers combined over $200 million in pharmacy costs and $50 million in medical and surgical costs every year on average.

Prior authorization means a doctor, in certain cases, files a request with a patient’s insurance company for certain prescription drugs, as well as for some medical and surgical procedures, before they are paid for by the patient’s insurance policy and pursued as treatment. Evidence-based guidelines are used to review the medical need and appropriateness of the treatment that the provider is seeking.

This process is collaborative between physicians and ensures patients receive the right care, at the right time, at the right cost.

In addition to benefitting patients, prior authorization helps Blue Cross fulfill our commitment to customers to contain costs and avoid unnecessary spending and waste.  For every dollar Blue Cross spends on medical and surgical care that requires prior authorization, customers and members save four dollars.

Prior authorization is also helping Blue Cross and Blue Care Network fight back against the opioid addiction and overdose crisis.

Beginning February 2019, prior authorization is required the first time a member’s dosage surpasses 90 morphine milligram equivalents per day. Higher opioid dosages can provide long-term pain relief for some, but they can also increase the risk of overdose and even death. Patients who receive 100 morphine milligram equivalents per day are nearly nine times more likely to overdose than those on 20 morphine milligram equivalents or less.

In numerous cases, prior authorization has protected our members from receiving the incorrect medication or dosage.

In one instance, a young adult had been taking a drug for a rare and severe seizure disorder in the hospital. As they were being discharged, the prescription request was for double the dose that the patient had been taking. The Blue Cross clinical pharmacist reviewing the case noticed the discrepancy and acted, calling the nurse to verify the treatment plan and correct the dose. Without this safety check, the double dose of the drug could have caused the patient central nervous depression, low blood pressure, sedation, trouble breathing and possibly coma or death.

At Blue Cross, prior authorization is required for drugs that have dangerous side effects, are harmful when combined with other drugs, that should only be used for certain health conditions, are often misused or abused and that may have a less expensive equivalent. For pharmacy, non-urgent requests to Blue Cross for prior authorization for drug coverage are decided within 72 hours. When an urgent review of a drug not covered by your plan is requested, Blue Cross will make a decision within 24 hours or less. Standard drug reviews may take up to 15 days to decide.   In addition, Blue Cross offers physicians the ability to use its electronic prior authorization process for drug reviews to expedite the process and lessen the administrative work for the physician.

Some of the medical and surgical procedures that require prior authorization are joint replacements, prosthetics, transplant services and genetic testing. Patients have the right to appeal any prior authorization denial decisions.

Blue Cross is committed to making health care more effective and more affordable. Prior authorization is an essential part of health care cost management and ensuring customers have access to safe, cost-effective medications and medical procedures when they need them.

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