Health insurance companies increasingly employ cost management strategies as more expensive, specialized drugs enter the market. The use of step therapy is one of these cost-control strategies. The goal of step therapy is for patients to try low-cost medications before moving on to more costly ones.
Author Archives: ACMA
Will Prescriber “Gold Cards” Solve the Prior Authorization Problem?
Imagine a world with fewer prior authorizations. A new Texas law aims to make this dream a reality. House Bill 3459(HB 3459), or the “Gold Card Act,” grants prescribers a “continuous prior authorization exemption” if they have a 90% approval rating on previous authorization requests.
The Players of Prior Authorization
The prior authorization (prior auth, or PA) process itself can be complicated and requires both communication and a cohesive healthcare team. The healthcare team involved in the PA process consists of a provider or physician, the pharmacy, the payer, and the patient. Each player on this team plays a part in successful and positive patient outcomes.
The Evolution of Prior Authorizations
With a solid foundation of prior authorizations, pharmacies are able to bill the medication sooner, physicians are able to focus resources on patient care instead of paperwork, and the patient receives their medication in a timely manner.
The Definitive Guide to Prior Authorization
Gain insights into everything that prior authorization entails in this guide.
What is Traditional Medicare vs. Medicare Advantage?
With so many healthcare options available in the United States, it can be difficult and confusing choosing the right option for you. In this article, we will explain the differences between Medicare vs. Medicare Advantage. To start, Medicare Advantage provides a fixed set of options for you whereas Medicare provides you with a “buffet” style […]
What are Copay Maximizers and Accumulators?
A recent article in the American Journal of Managed Care shed light on copay maximizer strategies among generics manufacturers. But not many patients understand how drug manufacturers are incorporating copay maximizers and accumulators in their reimbursement strategies. As a widespread challenge for patient access, copay accumulators and maximizers eliminate the altruistic nature of the patient assistance […]
Prior Authorizations are becoming a bigger burden- Now what?
For physicians like Terrence Regan, MD, a Urologist in Florida, prior authorizations are limiting access to important treatments for patients and are draining physician offices of resources and time. According to the American Medical Association, 92% of care delays can be traced back to prior authorization requirements and 1 in 4 patients in 2021 will […]
Field Reimbursement Now-Controversy between the FDA and Biogen
On July 9, the current acting FDA Commissioner Janet Woodcock called for the Office of Inspector General to investigate the agency’s close ties with Biogen who had submitted its Alzheimer’s drug, Aduhelm for FDA approval. Aduhelm is a monoclonal antibody for the treatment of Alzheimer’s disease, was extremely controversial when it was first approved due […]
What is an Insurance Exclusion List?
A drug exclusion list is a list of medications that will not be covered by a health plan for any reason. The drug is not on formulary and there are no loopholes to gaining approval. What is a formulary? A formulary is a list of prescription drugs covered by a prescription drug plan or another […]
