Prior authorisation (revision 6)
Old revision·07:54, 30 Jan 2025·FmocFrancis
| Prior authorisation | |
|---|---|
| Also called | Pre-authorisation, pre-approval |
| Decided by | The payer, not the prescriber |
| Common criteria | Body-mass index, comorbidity, prior therapy |
| Topic infobox · conventions | |
Prior authorisation is a requirement imposed by a payer that a prescription be approved before it will be covered. It is a coverage mechanism rather than a clinical one, and the decision is made by the payer against its own criteria.[1]
For incretin therapies it is close to universal where these drugs are covered at all, and the criteria commonly include a body-mass index threshold, a comorbidity, documented prior attempts at other management, and sometimes a requirement to try a specified alternative first.[1]
Its effect on access is substantial. Requirements add delay, administrative burden on prescribers, and a failure mode in which coverage is denied for a prescription a clinician judged appropriate.[2]
How it operates
[edit]A prescriber submits a request with supporting documentation; the payer assesses it against published or unpublished criteria; approval, denial, or a request for further information follows. Denials may be appealed, in a process with its own timelines.[2]
Step therapy — a requirement to have tried and failed a specified alternative — is a common form. Its rationale is cost containment; its cost is delay and, where the specified alternative is less effective, a period of less effective treatment.[1]
Reauthorisation is often required periodically, sometimes conditional on documented response such as a minimum weight reduction. A person who responds moderately may therefore lose coverage.[2]