Having access to the right prescription drugs can literally save lives. According to the U.S. Food and Drug Administration (FDA), there are currently more than 20,000 different prescription medications approved for marketing. Knowing which drug works best for an individual disease state is a complex process even without factoring in the potential cost of treatment. When cost becomes a factor, however, it can be nearly impossible to know which drugs to cover and which to exclude. This is why selecting a  pharmacy benefit manager (PBM) like PharmAvail becomes so important.

PharmAvail partners with a national Pharmacy and Therapeutics Committee to manage our list of covered drugs (also known as a formulary). Once an employer group’s formulary has been approved, the next step in maximizing the benefit is utilizing our prior authorization program.

While our prior authorization program is designed to ensure members receive the most effective drugs at the best prices, our benefit programs are not a one-size-fits-all offering. Consider the following two companies: Company A is privately owned with a strict emphasis on low-cost offerings. Company B is backed by private equity and believes strong benefits lead to higher employee retention. With differing priorities, these two companies are looking for different benefit program structures.

Once PharmAvail understands the goals of the plan sponsor, our team develops a prior authorization program focused on minimizing plan costs while maximizing drug effectiveness. PharmAvail recommends that clients implement both our standard Prior Authorization and Step Therapy programs. Used in tandem, PharmAvail’s clinical staff is able to process claims, manage approvals, analyze data, find drug alternatives, and monitor the entire process. The goal of these tools is to encourage the appropriate use of less-costly alternative medications.

The prior authorization process begins just like any other prescription claim, at the prescriber’s office.

Scenario #2

After visiting with her doctor, Mary is ready to try a new medication to treat her chronic migraines. She has tried topiramate, a central nervous system analgesic, that can be taken for prevention of migraines. She also has tried propranolol, a beta blocker that can cross the blood brain barrier and lower the pressure that triggers migraines.

Dr. Grover believes that Emgality, a newer and more expensive injection used once monthly for migraine prevention, will have better efficacy. As part of the prior authorization process, he sends in office notes showing that Mary has tried and failed both topiramate and propranolol. He also sends in some literature supporting why he believes Mary will respond well to Emgality. After review by a clinical pharmacist or physician, PharmAvail’s Clinical Services department agrees with Dr. Grover’s assessment and the prescription is approved. Mary may now fill the prescription for Emgality, and even though the cost is higher for the Emgality, it is likely her migraine frequency and severity will improve.

While cost containment is an important element to the services we offer, facilitating member access to needed medications is our top priority. As our team considers each prior authorization request, we ask ourselves the following questions:

• Is the patient new to the drug therapy?
• What medications were they taking before?
• How can we maintain the quality of care they are used to receiving?

PharmAvail takes a holistic approach to creating and managing our prior authorization process while providing access to the needed prescriptions that will facilitate a better quality of life.