BlueCross Implements Efficient Prior Authorization

Nationwide, prescription drugs represent the most expensive and frequently used health plan benefit. Last year, BlueCross allocated over $3 billion on medications for our members. 

Each of these dollars originated from a BlueCross customer, so it’s crucial for us to manage our resources efficiently. Prior authorization (PA) is a tool we utilize to help control these costs. More importantly, it serves as a safety measure. Our objective is to ensure our members receive the right drug, in the right dose, for the right individual, and in the right setting. 

When making decisions, we consider the complete picture of a member’s condition and unique experience — at both policy and individual levels. This involves evaluating cost, efficacy, and potential drug interactions against the overall benefits of a prescription medication. Some drugs, if prescribed incorrectly, can cause harm. PAs help reduce off-label usage, where doctors prescribe drugs for conditions that the Food and Drug Administration (FDA) hasn’t reviewed and approved. 

Advancements in technology make the process simpler and faster 

Healthcare providers make over 300,000 prior authorization requests annually for BlueCross members. By monitoring and approving these prescriptions, we ensure safety and help keep premiums affordable for all our members. 

Our commitment to value is just one way we’re alleviating the burden on our members. We use PAs when a more affordable drug, with proven equal efficacy, is available compared to a more expensive option. Conversely, a costly medication can prevent emergency room visits and hospitalizations, potentially saving money by covering a more expensive drug. 

We’ve also adopted new technology to streamline the PA process, allowing providers to submit authorizations electronically. These electronic submissions result in faster turnaround times, and providers can track the status of each prior authorization in real-time on a dashboard. 

Contrary to popular belief, most prior authorizations are approved 

Sometimes, our members and providers don’t need to be involved in the PA process. Claims information can enable a prescription to proceed without a “hard stop” at the pharmacy. For instance, if someone has Type 2 diabetes and a related medical claim, certain diabetes medications that typically require a PA will process without additional information. We refer to these as “smart PAs.” 

We’ve recognized the benefits of bringing the PA process in-house, from an external pharmacy benefits company to our own teams of credentialed specialists. This applies to medications usually taken by members themselves, as well as those administered in doctors’ offices or hospitals. It reduces steps for providers, improves turnaround time, and further lowers costs for our members. 

We understand that information on medications can change. That’s why we continuously evaluate clinical studies. A drug may receive a new indication — its use for treating a particular disease — and we meet weekly to assess any new indications. Alternatively, a drug might be removed from the market if found to be ineffective or unsafe. 

There’s a common misconception that prior authorizations (PAs) exist solely to deny healthcare and treatment. At BlueCross, the majority of PA requests are approved. When used correctly, medications can improve and save lives. However, improper drug use is dangerous — adverse reactions can lead to hospitalization and death. For us, preventing these human costs makes prior authorizations worthwhile.