Development of a specialty medication prior-authorization service at an urban academic medical center

Purpose. The project in which a clinical pharmacist enlisted the help of pharmacy students to create a team responsible for prior-authorization (PA) paperwork associated with hepatitis C virus (HCV) infection treatment is described. Summary. Many insurance companies require completion of a time-consuming PA process for approval of high-cost specialty medications, such as those used in the treatment of HCV infection. A clinical pharmacist at an urban academic medical center recruited pharmacy students to assist with and streamline the HCV medication PA process. After training, the students developed a protocol to increase the efficiency of completing PA requests, appealing denials, obtaining PA extensions, and documenting progress in the electronic medical record to ensure continuity of care. The PA team collaborated with clinicians to document proof of medical need and worked with insurers, pharmacies, and patients to achieve timely approval and receipt of medications. From June 2014 to March 2015, three students spent 240 hours developing the PA protocol and completing 88 PA requests, with an overall medication approval rate of 87.7%; 18 patients were also referred to medication assistance programs. The PA team's work allowed the clinical pharmacist to spend more time on clinical activities and scholarship, while the students increased their knowledge of HCV disease and HCV-targeted therapies and improved their skills in written and verbal communication with patients, providers, and insurance companies. Conclusion. Pharmacy students successfully implemented a PA team to manage prescription approval for HCV medications with assistance from a clinical pharmacist.