PA Program Design
| Element | Best Practice |
|---|---|
| Drug selection | Target high-cost, high-risk, or frequently misused drugs |
| Clinical criteria | Evidence-based criteria from clinical guidelines |
| Turnaround time | Urgent: 24 hours; routine: 3–5 business days |
| Appeals process | First-level appeal within 30 days; expedited appeal within 72 hours |
| Physician communication | Clear communication of criteria and decision rationale |
| Retrospective review | Review of claims for drugs that should have required PA |
Evidence-Based Criteria
PA criteria must be evidence-based — grounded in clinical guidelines and peer-reviewed evidence. Criteria that are purely financially motivated — requiring PA for drugs where PA is not clinically appropriate — are both ineffective and potentially harmful. Work with a clinical pharmacist to develop evidence-based PA criteria for each targeted drug category.
PA Burden
Watch Out
PA programs that are too broad — requiring PA for too many drugs — create administrative burden for physicians and delays in care for patients. PA burden is a growing concern — the AMA reports that physicians spend 14 hours per week on PA requests. Design PA programs that target the highest-value opportunities and minimize administrative burden for appropriate prescribing.