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Prior Authorization Criteria with Efficacy, Dosing, Frequency, Combination Therapy & Cost

Pre-Certs should ensure the appropriate use of medications. We have solutions that support specialty drug approvals for medical and pharmacy benefits. Reviews can range from basic approvals to in-depth patient reviews.

We evaluate benefit compliance as the reviewer, for self-insured employers and health plans.

    Benefit compliance is based on several factors:
  • Is the request a covered benefit?
  • Is it FDA approved for the supplied diagnosis?
  • Are the multi-dose or single-dose vials wasted?
  • Does the claim meet contract pricing requirements?
  • Are the quantities and dosages compliant with benefit limitations?
  • Has the companion genomic testing met standard criteria?

Specialty medications are reviewed daily, on an “as needed” basis, as a pre-certification, or an in-depth chart review for benefit approved indications.

    Important client benefits are:
  • Support for therapy for extraordinary circumstances
  • Authorization based on strict benefit and FDA criteria for medication usage
  • Authorization based on fair and equitable cost reduction methodologies
  • Identification of patients that will receive the greatest benefit from the proposed therapy
  • Avoid duplicate payments in medical and pharmacy

Pre-Certification of Specialty Medications at Work

Problem: One of our clients was concerned about comparing the medical versus the pharmacy specialty spend. Their primary concerns were the location of service and applicable costs, as well as the overall gross trend of their per-member-per-month (PMPM) trends. Separately, the clinical group within the organization wanted to know if their clinical cost control methods were effective on a total Plan as well as on a per provider basis.

Methodology: We analyzed every specialty medication claim from both medical and pharmacy data for this client each month. All findings were filtered by location of service, PMPM, provider specialty, disease/condition, provider, etc.

The analyses reported overall performance and compliance with a series of outliers – e.g., unmatched diagnoses, medications without applicable genomic testing, dosage within labeled min/max ranges, quantities within expected usage, pricing vs. lowest cost, pricing in compliance with contracts, rebates, value of wastage, etc. For the clinical group, all claims were analyzed for prior authorizations (PAs) for formulary exclusions, efficiency of prior authorizations and step therapy, adherence by drug and by category, etc.

Outcome: Financial savings for our client were identified on average of 42-44% of paid amounts. Clinical analyses identified beginning compliance of 50% and cost control methods, including PAs at 60% efficiency. After the implementation of the new process, the compliance increased above 80% and clinical cost control efficiency was above 70%.

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