LaPensee Kenneth T
Cambridge Pharma Consultancy, 80 Broad St., 35th Floor, New York, NY 10004, USA.
J Manag Care Pharm. 2003 Jan-Feb;9(1):36-44. doi: 10.18553/jmcp.2003.9.1.36.
To determine the factors important in approving prescription reimbursement under prior authorization (PA) in a Medicaid managed care organization (MCO).
A cross-sectional statistical analysis was performed using administrative data for one month of PA requests to an MCO with more than 250,000 Medicaid recipients in the northeast United States.
More than 95% of PA reviews resulted in payment for the originally prescribed products. The most common treatments involved were atypical antipsychotics, antacids, antidepressants, antihypertensives, anticonvulsants, and Cox-2 inhibitors. The rejection rate for nonformulary products was 7.1% while that for formulary products was 3.7%. Nevertheless, most drugs requiring PA were formulary- listed, with protocols to reinforce prescription guidelines. Rejection of reimbursement was inversely related to patient age. Most likely to be authorized were drugs for smoking cessation, pain, and nausea, while those least likely to be approved were multivitamins, sleep aids, and high-cost antidepressants.
Although nonformulary products are more frequently subject to PA, 78.6% of PA procedures are performed in response to requests for formulary-listed products. The PA rejection rate for this Medicaid MCO was small; 4.4% overall and 7.1% for nonformulary versus 3.7% for formulary drugs.
确定在美国东北部一个拥有超过25万医疗补助计划参保人的医疗补助管理式医疗组织（MCO）中，事先授权（PA）下批准处方报销的重要因素。
使用向该MCO提交的一个月PA申请的管理数据进行横断面统计分析。
超过95%的PA审查导致为最初开具的产品支付费用。涉及的最常见治疗药物为非典型抗精神病药、抗酸剂、抗抑郁药、抗高血压药、抗惊厥药和环氧化酶-2抑制剂。非处方产品的拒付率为7.1%，而处方产品的拒付率为3.7%。然而，大多数需要PA的药物都在处方清单上，并有强化处方指南的方案。报销拒付与患者年龄呈负相关。最有可能被批准的是戒烟、止痛和止吐药物，而最不可能被批准的是多种维生素、助眠药物和高成本抗抑郁药。
尽管非处方产品更频繁地需要PA，但78.6%的PA程序是因对处方清单上产品的申请而进行的。该医疗补助MCO的PA拒付率较低；总体为4.4%，非处方产品为7.1%，处方药物为3.7%。
