What is Prior Authorization?

Whether a patient has coverage through Medicaid or a private plan, access to the mental health products and services they need should be equitable. Action is necessary to create and preserve that access.

Both public and private payers are increasingly imposing restrictive utilization management (UM) policies that hinder access to drugs for mental health conditions. Such policies decrease adherence, increase medical costs over time (which eclipses any expected savings from reduced medication use), and lead to negative clinical outcomes for patients. However, studies show that removing UM policies for patients with mental health conditions decreases hospital admissions and emergency care costs.

Examples of UM policies include:

“Prior Authorization”

1

“Prior authorization,” which requires that – before a drug can be dispensed – a payer review the patient’s health record and information as to why treatment is being sought, and approve or deny coverage. This second-guesses a health care provider’s judgement, and may not take into account a patient’s full history.

“Step Therapy”

2

“Step therapy,” an insurer-created regimen for a condition where a patient must fail on a drug and demonstrate it is ineffective in order to proceed to the next medication, each being a so-called “step.” This almost always requires initial generic drug usage, and undermines physician clinical judgement and patient preferences.

“Preferred Drug Lists”

3

“Preferred drug lists,” which outline the drugs a state encourages providers to prescribe over others. Agencies that oversee Medicaid programs make these lists, and often have financial – vs. clinical – motivations.