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

Prior Authorization at Work

Pro Pharma Pharmaceutical Consultants, Inc has been consulting in Managed Care for many years and worked with a wide variety of Health Plans, Municipalities, Self-Insured Companies, and more.

Included in these consulting services are Prior Authorizations and Pre-certification Reviews. Whether standard or specialty drugs, requests can be sent securely. We can work within your established guidelines and Formulary along with product and industry standards.

There may be times when in-depth Patient Reviews are required. Pro Pharma will review the material available such as medical history, current medication regimen, past and present diagnoses, lab results, and any physician notes available. We use this information to determine the need for the requested medication or treatment and can give recommendations – whether to approve or deny requested medications or if more tests and/or alternative treatment would be best for the patient.