Electronic Prior Authorization Reform: What’s Next?

The legislation will streamline the prior authorization process for the more than 28 million Medicare Advantage members. Medicare Advantage (MA) plans, sometimes called “Part C” or “MA Plans,” are Medicare-approved plans from private companies offering an alternative to original Medicare for health and medication coverage.

4 Tips for Prior Authorization Success

Prior authorizations (prior auths or PAs) are a cost management tool utilized by insurance companies. PAs increase administrative costs for HCPs and create a healthcare obstacle for patients. HCPs depend on prior authorization approvals and insurance payments to remain in business. Healthcare providers (HCPs) must master a productive prior authorization workflow to improve productivity and revenue.

An Essential Guide to Step Therapy

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.

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.

What is a Drug Pricing and Reimbursement Strategy?

When a pharmaceutical company launches a new product, pricing and reimbursement would be established in order for the product to come into the market. The price of a product comes from the negotiation between manufacturers and payers. Payers make decisions on what drugs and devices are made available to patients and at what cost. Products […]

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 […]