A Pharmacist-Led Consult Service and Prior Authorization Recertification Program for patients with Medicaid

August 27, 2020

Prior authorization (PA) is a utilization management tool used to support safe, appropriate, and cost-effective use of medications. PA has both supporters and detractors, with both sides bringing equally important objectives and concerns to the table. As an organization that serves Medicaid programs and other payers, Commonwealth Medicine supports the role of PA, but recognizes that all PA programs are not created equal. In January 2020, the Academy of Managed Care Pharmacy (AMCP) convened a forum to address calls to improve the PA process and highlighted several best practices and opportunities for improvement.

Among the AMCP recommendations is a call for effective communication to ensure timely completion of PA requests and minimize delays in care. PAs are often issued for a finite duration of approval, which should prompt prescriber re-evaluation for continued need of the drug. Given the volume of PAs and the number of patients that an office may manage, PAs are not always resubmitted for recertification of medically necessary therapies before expiration. As a result, patients who visit their local pharmacy expecting to pick up a prescription may not be able to access their medication.

Supporting PAs for medically complex patients: collaboration and coordination

Patients with chronic health conditions who are considered medically complex may require more drug treatments than the general population. For these individuals, when a PA is not renewed promptly, the result may be an increased risk of treatment delays and reduced medication adherence, both of which may worsen patient outcomes and increase medical costs.

To address this problem, Clinical Pharmacy Services (CPS) implemented a PA recertification program for the MassHealth (Massachusetts Medicaid) Special Populations Program, which was established in 2006 as a unique strategy to enhance the quality of care for patients with complex chronic health conditions. Among the features of the Special Populations Program is close collaboration and coordination of care between the Community Case Management (CCM) and Enhanced Coordination of Benefits programs.

For adult and pediatric patients with chronic health conditions, CCM coordinates various in-home skilled nursing services, including physical therapy, procurement of medical equipment, and home/personal support. Special Populations Pharmacists provide consult services to treating physicians and clinical managers, helping streamline drug regimens for clinical efficacy and cost-effectiveness, assisting in medication procurement and facilitating insurance coverage for over-the-counter drugs, and identifying pharmacies that offer special formulations of drugs.

From December 2019 to February 2020, the CPS Special Populations Program pharmacy team implemented a three-month PA recertification program, led by Soumya Vishwanath, PharmD, Managed Care Pharmacy Resident. This program aimed to minimize potential gaps in continuity of care through proactive intervention, prompting providers to submit new PA requests before expiration. Outreach included contact via telephone and facsimile within two weeks of PA expiration and discussing the need for continued treatment and proposing resubmission of PA as necessary.

On average, for the intervention group, PAs were submitted 2.7 days before the expiration date, versus 13.0 days after PA expiration in a historical comparison group, for which no prescriber outreach was conducted. The expectation is that with earlier PA resubmission, there will be fewer gaps in treatment, which will decrease unnecessary healthcare utilization related to medication non-adherence. Based on internal assessment and literature evaluation, a proactive PA intervention program such as this one produces an estimated return on investment of $14 per $1 spent on outreach, further underscoring the importance of pharmacist-led interventions and services for patients.

How can we enhance your PA program?

To learn more about how the CPS can help design effective clinical programs, reduce costs, and improve health outcomes, contact Bonnie Greenwood, PharmD, BCPS, Director, Clinical Programs, Clinical Pharmacy Services.


  1. AMCP Partnership Forum: Optimizing prior authorization for appropriate medication selection. Journal of Managed Care and Specialty Pharmacy. 2020;26(1):55-62. Available at: https://www.jmcp.org/doi/full/10.18553/jmcp.2020.26.1.55
  2. New England Healthcare Institute. Thinking Outside the Pillbox: A system-wide approach to improving patient medication adherence for chronic disease, A NEHI Research Brief [monograph on the internet]. Cambridge (MA): Network for Excellence in Health Innovation: 2009 Aug [cited 2020 Aug 26]. Available from: http://www.nehi.net/writable/publication_files/file/pa_issue_brief_final....
  3. Commonwealth Medicine. Boston Globe: Community Case Management program provides caregivers for families of medically complex children [webpage on the internet]. Shrewsbury (MA): Commonwealth Medicine. 2014 [cited 2020 Aug 26]. Available from: https://commed.umassmed.edu/news/2014/02/10/boston-globe-profiles-family....
  4. Commonwealth Medicine. Community Case Management [webpage on the internet]. Shrewsbury (MA): Commonwealth Medicine. 2019 [cited 2020 Aug 26]. Available from: https://commed.umassmed.edu/our-work/2018/01/28/commun.
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