Transcript Prior Authorization - Academy of Managed Care Pharmacy

Principles in Practice
Prior Authorization
Copyright © 2002 – 2005 – Academy of Managed Care Pharmacy (AMCP)
Slide 1
Managed
Care
Organization
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(MCO)
• An organization with one or more products
that integrate financing and management
with the delivery of health care services to
an enrolled population.
Navarro RP. Managed Care Pharmacy Practice. Gaithersburg, MD: Aspen Publishers;1999.
Copyright © 2002 – 2005 – Academy of Managed Care Pharmacy (AMCP)
Slide 2
Pharmacy and Therapeutics (P&T)
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Committee
• The Pharmacy and Therapeutics Committee is a
Committee of Health Care professionals responsible for
the development and surveillance of all medication use
policies and practices to assure optimum clinical results
and a minimum potential for hazard to patients. The
Pharmacy and Therapeutics Committee has three primary
functions:
– Formulary Maintenance
– Safe Medication Use
– Medication Use Evaluation
Copyright © 2002 – 2005 – Academy of Managed Care Pharmacy (AMCP)
Slide 3
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Formulary
Management
• An integrated patient care process that
enables physicians, pharmacists and other
healthcare professionals to work together to
promote clinically sound, cost-effective
pharmaceutical care.
Academy of Managed Care Pharmacy. Concepts in Managed Care Pharmacy Series
Pharmaceutical Care. 1997.
Copyright © 2002 – 2005 – Academy of Managed Care Pharmacy (AMCP)
Slide 4
Priorand
Authorization
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• Protocols placed on medications to prevent
their prescribing unless defined and specific
criteria are met. Often, the agents subject to
prior authorization are medications with a
potential for misuse or inappropriate use.
Navarro RP. Managed Care Pharmacy Practice. Gaithersburg, MD: Aspen Publishers;1999.
Concepts in Managed Care Pharmacy Series, Prior Authorization and the Formulary Exception Process,
Academy of Managed Care Pharmacy. Alexandria, VA: 2005
Copyright © 2002 – 2005 – Academy of Managed Care Pharmacy (AMCP)
Slide 5
Click
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On-Line
Messaging
• The process of electronically transmitting
data to the point of prescribing subsequent
to the creation of a prescription order or
record for the purpose of providing the
pharmacist with product coverage and
safety information.
Copyright © 2002 – 2005 – Academy of Managed Care Pharmacy (AMCP)
Slide 6
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Clinical
Practice
Guidelines
• A utilization and quality management
mechanism designed to aid providers in
making decisions about the most
appropriate course of treatment for a
specific clinical case.
Copyright © 2002 – 2005 – Academy of Managed Care Pharmacy (AMCP)
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