Prior Authorization

The Prior Authorization process requires physicians to obtain approval from pharmacy benefits plans before payment for medication is approved.  This process delays patients’ ability to obtain necessary medication and/or treatment.  It also presents time-consuming administrative burdens on physicians, which can lead to a decreased number of patients the physician can treat.

Non-physicians are usually hired by insurance companies to make the decision about whether to approve prior authorization requests submitted by the treating physician.  This process allows for non-physicians to block physician-chosen and patient-accepted treatments.  The prior authorization process can interfere with the continuity of care for patients involved in an active course of treatment, as well as access to prescription medication for patients on chronic, established therapy.

For individuals with psychiatric disorders, including those with serious mental illness or substance use disorders, gaps in treatment, due to prior authorization denials, can lead to loss of treatment, relapse with increased care costs, and higher rates of suicide and opioid overdose deaths.

The prior authorization process takes significant physician time away from patient care.  As discussed, the impact on patients and physicians of the prior authorization process is significant, and yet there is no evidence of improved outcomes for patients, as well as no evidence that it results in cost savings.

The NJPA strongly supports revisions to the prior authorization process and requirements with the goals of promoting safe, timely, and affordable access to evidence-based care for patients; enhancing efficiency and reducing administrative burdens.  Prior authorization decisions must be:  made by physicians, support standards of care, and eliminate unnecessary administrative burdens.

The prior authorization process should be revised to narrowly target adherence to evidence-based medicine, as opposed to the current focus on a wide range of treatment/medication reviews.

AMA Consensus Statement on Prior Authorization
AMA Toolkit on Prior Authorization
NJPA Talking Points on Prior Authorization

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