Prior Authorization

Prior Authorization (PA) is the practice of restricting access to prescribed medications by insurers or payers based on certain criteria. This is accomplished by requiring that a prescription medication receive special approval by the insurer prior to being filled by the pharmacy. Prior Authorization properly used can help direct patients to appropriate treatments. Unfortunately, prior authorization is increasingly being used as a tool by insurers to slow or stop the use of high-cost medications, even when they are the standard of care for that condition. Prior Authorization restrictions on HIV and HCV medications is a serious and growing issue for both HIV providers and patients.

For patients living with HIV prior authorization requirements can mean unnecessary delays in getting the medications they need to manage their health condition.

HIV & Prior Authorization

Disruptions or delay in treatment can have life-threatening consequences to individuals living with HIV.

This is why HIV-related drugs (including both antiretrovirals and other drugs used to treat co-occurring conditions) must be treated differently than other drugs in coverage formularies.

Cumbersome authorization requirements for HIV treatment can actually lead to more medical complications, higher treatments costs, and worse health outcomes.

Ultimately, this represents a “cost” to the health system in additional medical bills, hospitalizations, and lost productivity of patients.

Prescriber Prevails

As an organization of front-line HIV care providers, we support the ability of providers to determine the best course of treatment for their patients.

We also generally support initiatives to improve the health system and cost efficiency of public programs. We appreciate the budgetary impetus behind cost-savings initiatives when significant savings are involved and patient outcomes are unlikely to be strongly affected. We also respect the burden on state and federal officials to balance budgetary considerations.

We make a large distinction, however, between medications generally and life-saving drugs for patients (including those living with HIV) with a life-threatening and communicable disease. The latter should largely be held exempt from general programmatic budgetary discussions.

Certain classes of drugs — in direct proportion to the severity of the conditions they treat and with consideration for the medication’s requirements for efficacy — should be held as exempt from regular policy changes and political maneuvering.

We believe that the best determination of appropriate medical treatment for people living with HIV occurs in the relationship between provider and patient. HIV drug treatment is a highly individualized medical intervention that requires constant provider monitoring and adjustment.

We fully support so-called “Prescriber Prevails” rules that allow the professional opinion of medical care providers to determine the final condition for approval and coverage of a prescribed medication.

Medicare Part D “Protected Classes” Model

We believe the Medicare Part D model of six protected classes of drugs represents a good example of ensuring that life-saving medications are made available to the patients who need them. We support this model for HIV drugs and also for other medications used to treat side effects of these drugs, other infections and co-occurring conditions common with HIV.