Prior authorization (PA) is a gatekeeping mechanism put in place in some health care programs whereby a patient or provider must obtain special approval prior to the dispensing of a particular set of drugs. Individuals within the health care payer organization approve or deny a particular prescription request based on a defined set of criteria. PA requirements have been criticized for creating a physician "hassle factor," that is to say, the documentation required to get a PA drug approved is too burdensome for most physicians to be willing to pursue.
The rationale for using PA is based on several assumptions. These may include:
- No clinically important efficacy or effectiveness differences exist between two agents of a given class. Therefore, it is only necessary to reimburse one of these agents on a routine basis.
- Clinically important safety differences exist between two agents of a given class. Therefore, it is necessary to require special permission to dispense a particular drug to insure consumer protection.
The agents designated for prior authorization have the potential for abuse by either providers or patients. Therefore it is necessary to restrict access to these agents and document clinical necessity prior to dispensing.
The agents designated for prior authorization are more expensive than other alternatives, while their increased benefit is less clear. Because lowering pharmaceutical expenditures is a valid endpoint in its own right or directly correlates with overall medical cost savings, dispensing of the more expensive agent should require special permission.