Medications requiring prior authorization across health insurance plans
Medications requiring prior authorization across health insurance plans
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DOI：
10.1093/ajhp/zxaa031
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发表时间：
2020-04-15
影响因子：
2.7
通讯作者：
Graham, Jove
中科院分区：
文献类型：
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作者：
Jones, Laney K.;Ladd, Ilene G.;Graham, Jove
目标。根据保险计划和类型确定需要事先授权（PA）的药物数量和类型的变化量。大多数健康保险公司都要求药品授权，以确保安全有效的使用，并控制成本。我们生成了2017年商业、市场、医疗补助和医疗保险计划需要PA的4种药物清单。我们使用代码和药物名称根据仿制药名称等效物汇总药物。我们比较了这些药物，以评估1、2、3或全部4种保险计划中有多少药物需要PA。我们通过查询电子健康记录，统计了2017年期间18岁或以上的健康计划保险患者在健康计划PA列表中出现的任何药物的所有处方订单。2017年，4个计划中的600种独特药物需要PA。在114,159名会员的691,457份处方单中，31,631份（5%）是针对至少一项保险计划要求PA的600种药物中的一种。有12,540个药物订单（为6,642名成员写的）可能需要PA。市场计划要求PA的药物数量最多（440种），其次是医疗保险（272种），商业（271种）和医疗补助（72种）计划。至少有一种计划需要PA的最常见的处方药物类别是降血脂药（22%的订单可能需要PA），麻醉性镇痛药（13%），催眠药（12%），降糖药（9%）和抗抑郁药（9%）。只有25%的药物（600个中的151个）至少有3个计划需要PA，只有5%（600个中的32个）所有4种保险类型都需要PA。结论：在同一家医疗保险公司内，需要PA的药物可能不同，但由于外部因素，这种差异可能是不可避免的。
Objective. To determine the amount of variation in numbers and types of medications requiring prior authorization (PA) by insurance plan and type.Methods. Most health insurance companies require PA for medications to ensure safe and effective use and contain costs. We generated 4 lists of medications that required PA during 2017 for commercial, marketplace, Medicaid, and Medicare plans. We aggregated medications according to the generic medication name equivalent using codes and medication names. We compared these medications to assess how many of the medications required PA by 1, 2, 3, or all 4 of the insurance plans. We counted all prescription orders written for a patient age 18 years or older with health plan insurance during 2017 for any of the medications that appeared on the health plan's PA lists by querying the electronic health record.Results. PA was required for 600 unique medications in 2017 across the 4 plans. Of 691,457 prescription orders written for 114,159 members, 31,631 (5%) were written for 1 of the 600 medications that required PA by at least 1 insurance plan. There were 12,540 medication orders (written for 6,642 members) that potentially required PA. The marketplace plan required PA for the greatest number of medications (440), followed by the Medicare (272), commercial (271), and Medicaid (72) plans. The most commonly prescribed classes of medications for which PA was required by at least 1 plan were antihyperlipidemics (22% of orders potentially requiring PA), narcotic analgesics (13%), hypnotics (12%), antidiabetic medications (9%), and antidepressants (9%). For only 25% of medications (151 of 600) was PA required by at least 3 plans, and for only 5% (32 of 600) was PA required by all 4 insurance types.Conclusion: Medications requiring PA can differ within a single health insurance company, but this variation may be unavoidable due to external factors.