Formulary Management:
Prior Authorization Process
C. Bernie Good
Jeanne Tuttle
March 2014, Informatics Call
Pharmacy Benefits Management Services
VA Central Office
Background
• At the recommendation of the Health Delivery
Committee (HDC), an interdisciplinary Pharmaceutical
Cost Proposal(s) Taskforce was formed to examine
options to prospectively address how VA can continue
to provide access to costly drugs while ensuring the
pharmacy benefit is sustainable well into the future.
• HDC, NLC approval, signed EDM.
• Evolve the National Formulary to include “Prior
Authorization”
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Formulary Evolution
• Formulary decisions will still be made by the
MAP/VPEs
• Prior Authorization is new formulary designation –
formalizes process for criteria for use
• Prior authorization reviews may take place at
National, VISN or Facility Level
• Designations on the posted formulary will be PA-N,
PA-V and PA-F
• Implementation will be staged
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Current
Process
New drug – MAP/VPE
Discuss Evidence and Vote
Non-Formulary
Formulary
Non-Formulary with
Criteria
Formulary With Criteria
Field
Implementation
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Future
Process
New drug – MAP/VPE
Discuss Evidence and Vote
Non-Formulary
Formulary
Formulary –
National Prior
Auth
Formulary –
VISN Prior Auth
Formulary With Criteria
Non-Formulary with
Criteria
Field
Implementation
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Prior Authorization Considerations
•
•
•
•
•
Cost
Volume
Marginal clinical benefit
Narrow spectrum of safety
Special significance to the mission of the VA (to
ensure access to all veterans)
• Subject matter experts
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Benefits of Centralized Approach
• Supported by field clinicians
– These can be very difficult and sometimes emotional
decisions and there is support to have them made centrally
• Decisions will be made objectively and will be evidencebased
• Less chance for inappropriate denials due to cost
• Promotes positive relationships between local prescribers
and formulary managers (reduced policing/gate keeping
tensions)
• Decreases the administrative burdens that would be necessary
to replicate these processes across all 21 VISNs
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Benefits of Centralized Approach
• Leverages the practices a small number of VISNs
have been able to implement and extends them to
the entire enterprise
• Improves ability to gather cost and patient outcome
data at a national level which will can be used to
determine value based decisions going forward
– Specifically, can better accommodate a “coverage with
evidence-development” scheme for particular drugs of
interest
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**DRAFT** National Prior
Authorization Process
• Inter-facility consults
– Existing technology, provider and informatics staff
familiarity
– Located under a CPRS screen that ensures high visibility for
providers – e.g. IFC section of CPRS and/or drug consults
menus.
– Keeps documentation within the EMR
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Inter-facility Consults
• Consult template developed nationally based on
MAP/VPE criteria determinations and sent out as TXML
file
• Facility level consult set-up and drug file management
• Hines VA is the receiving facility
• Expectation for turn around is 96 hours in alignment
with requirements for non-formulary reviews (VHA
Handbook 1108.08)
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Inter-facility Consult Set-up
Pharmacy ADPAC and CAC will need to work together on
local set-up
• Simultaneous notification to local pharmacy, Chief of
staff and National Reviewers when consult placed
• Creation of any associated drug quick orders or
“hiding” drug in CPRS alpha list
• Placement on menus (e.g. IFC menu, drug consult
menu, etc.)
– Menu structure different across facilities
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Menu Placement
• In deciding consider…
 Menu intuitive to providers – engage providers in
decision
 Facility Culture
 Teaching vs Non-Teaching Facility
 Additional provider training/education needed
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Example Consult Menus
All drug consults on same
menu separated by
inpatient and outpatient
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Example 2:
Prior Authorization Requests:
Placement choices: Use existing drug classification scheme OR
Create a new menu “Prior Authorization Medications”
Example 3: Using the “Alpha list”
LMNOP
311 < LMNOP>
Meds Prior Authorization
PA
This is a “Prior Authorization medication!
Please complete the Prior Authorization request
before ordering or contact pharmacy.
Prior Authorization Requests:
Placement choices:
1. Existing Meds Outpatient – provider receives an alert with quick order
2. Add new category “Meds Prior Authorization Request “ to house new and future requests
Drug File Management
• Drug File Management for Non-Formulary and
Criteria For Use medications varies widely across
facilities, therefore a standardized process for
handling PA medications will not be mandated
• Chief should ensure strong processes are in place
that ensures prescriptions will not be processed until
the prior authorization request is approved
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Drug File Management
Considerations
• Populate the message field of national prior
authorization medications with “National Prior Auth
Consult required”
• Create a place holder entry (in addition to the actual
drug) in the drug file that is not matched to the NDF
of an orderable item and contains information to
direct the provider to the consult location. See
additional presentations
– Thank-you to George Knight, VISN 2 VPE and Jennifer
Yahnian, Pharmacy Information Manager/ADPAC VA
Central California HCS (Fresno)
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Drug File Management
Considerations
• Mark the actual drug entry so that it does not appear
in the alpha list for providers to order and use a quick
order associated with the consult or have the
pharmacist enter the prescription through the
appropriate Pharmacy VistA package once the
consult is approved
• Develop a standardized process and educate staff on
how to manage prescription orders in the pending
file for national prior authorization medications prior
to approval
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Communication
• Mailgroup established to facilitate communication:
VHAPBH Prior Authorization National
• POC in PBM phone directory - Recommend populate
with Outlook Mailgroup
– Heads up on drugs requiring special ordering
– Help with requests for additional information if provider not
responding
– Notification of adjudication results
– Request for facilities to populate sent to VPEs 2/13
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Assessment of Outcomes
• Timeliness of response. These reports will
include IFC entry and response dates, appeals,
consult type and outcome of request.
• Prescription Processing. Prescriptions dispensed
to the facility prior to consult review and
adjudication. Will monitor fills without a consult.
• Patient Outcomes. In collaboration with local
facility, will track patient response and adverse
events to drug therapy and report quarterly to
MAP and VPEs.
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