TMA Supports Uniform Prescription Prior Authorization Form

TMA Testimony by Sharon Blancarte

Committee Subsitute HB 1032 by Rep. John Zerwas
March 5, 2013

Good afternoon, Chairman Smithee and members of the committee. My name is Sharon Blancarte. I am the office manager for Austin Internal Medicine Clinic, PA. On behalf of the Texas Medical Association (TMA) and 47,000 physicians and medical student members, I would like to thank you for the opportunity to testify on the committee substitute for House Bill 1032.

Texas physicians and their office staff support HB 1032 (like it's Senate companion, SB 644) because it will help our patients obtain their medications in a timely manner with less administrative complexity and hassle.  HB 1032 would create a uniform standard prior authorization request form for prescription drug benefits with input from a stakeholder workgroup at the Texas Department of Insurance (TDI). Once the standard form is developed, all insurers and health benefit managers will be required to use it. 

In my 30 years’ experience as an office administrator I am all too familiar dealing with an array of prescription drug prior authorization requirements and forms used by various insurers and pharmacy benefit managers here in Austin and surrounding counties. Physician offices often have contracts with:

  1. The s big five insurers: Aetna, BCBSTX, Cigna, Humana and United;
  2. Multiple smaller local plans;
  3. Medicaid
  4. Medicaid managed care plans;
  5. Children’s Health Insurance Program plans;
  6. Medicare Advantage plans
  7. Worker’s Compensation; and
  8. The State Employee Retirement System ; and
  9. The Teacher’s Retirement System.

You might think that represents only eight nine or so different forms for the physician and his or her staff to know and complete.  I wish that were the case!  The fact is every insurer, managed care plan or program I mentioned have many different prior authorization forms for their enrollee’s prescription drug coverage.  For example, I have attached a list of Aetna’s 49 AETNA SPECIALTY PRECERTIFICATION FORMS that must be completed to authorize specific drugs.  Even though the forms are similar to some degree, a separate form is needed for each of these drugs.  Sometimes two separate authorizations are needed when an IV drug is administered in the office:  In these cases I might be directed to contact both the insurer and the pharmacy benefit manager.

In order to know which prior authorization form to use for any given patient’s prescription and before a prescription can be written, the physician and staff have to know:

  1. Whether or not a prior authorization form is needed,
  2. The patient’s benefit design; and
  3. The health plan’s formulary as well as a drugs classification or tier within that formulary.

The process has become so unwieldy, we no longer keep prior authorization forms in our office.  Some practices have to dedicate one employee to do nothing but prior auths.  Unfortunately, I do not have that luxury since we are a small family owned practice.

Let me explain the process in my office to accommodate the current authorization requirements for prescription drugs:

  • We send the prescription request to the pharmacy;
  • The pharmacy tries to fill the prescription but its denied by the insurance company, as it requires prior authorization
  • A copy of the prescription is sent back to our office with “Prior Auth Necessary” on it. Sometimes the insurance company’s phone number is on there, sometimes it isn’t.
  • Our office calls the insurance company and they fax us the correct form.

No one can physically keep up with all the medications that require authorization any more.

Depending on the patient and the insurer’s formulary for that patient, we may need to use a different form or forms for every patient we see.  On a daily basis, that can range anywhere from three to forty prescriptions a day.

By decreasing the morass of authorization forms needing completion and subsequently the administrative time and burden, this bill will definitely assist in getting patients, including you and your constituents your prescriptions in a more efficient manner.

I want to thank you again for the opportunity to testify today. I ask on behalf of patients you support CSHB 1032 and pass this important piece of legislation out of your committee.

I’m happy to answer any of your questions.

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Last Updated On

May 20, 2016

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