Prior authorisation: difference between revisions
Diff·revision 2 → 3·17:16, 27 Dec 2024
Difference between revision 2 and revision 3 of Prior authorisation. 6 lines changed; the page grew by 767 bytes.
| Revision 2 — 11:31, 23 Dec 2024 ReaderRosalie (talk) clarify that coverage varies by plan and give the source for the example 1,025 bytes ±0 | Revision 3 — 17:16, 27 Dec 2024 eGFR_Esme (talk) add the note that prices below the list price are not evidence of a counterfeit 1,792 bytes +767 | ||
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| 10 | 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.{{r|ada2024}} | 10 | 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.{{r|ada2024}} |
| 11 | 11 | ||
| + | 12 | == How it operates == | |
| + | 13 | A prescriber submits a request with supporting documentation; the payer assesses it against published or unpublished criteria; approval, denial, or a request for further information follows.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.{{r|kyle2021}} | |
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| + | 15 | 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.{{r|ada2024}} | |
| + | 16 | ||
| 12 | == References == | 17 | == References == |
| 13 | {{reflist}} | 18 | {{reflist}} |
| 14 | <ref name="ada2024">American Diabetes Association. "Standards of Care in Diabetes." ''Diabetes Care'' 47(Suppl 1) (2024).</ref> | 19 | <ref name="ada2024">American Diabetes Association. "Standards of Care in Diabetes." ''Diabetes Care'' 47(Suppl 1) (2024).</ref> |
| + | 20 | <ref name="kyle2021">Kyle TK, Stanford FC. "Moving toward health policy that respects both science and people living with obesity." ''Nursing Clinics of North America'' 56(4):635–645 (2021). PMID 34749900.</ref> | |
| 15 | 21 | ||
| 16 | {{DEFAULTSORT:Prior authorisation}} | 22 | {{DEFAULTSORT:Prior authorisation}} |