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Seth Ginsberg: Biologics and Prior Authorization


Seth Ginsberg, co-founder and president of the Global Healthy Living Foundation, discusses the impact of prior authorization requirements on patients and providers.


How do prior authorizations affect patients who have been prescribed biologics?

Like “fail first,” prior authorization is a tactic used by health insurance providers to reduce prescription drug costs. They serve an important purpose in seeking to reduce healthcare costs; however, when they are excessive in length and difficult to navigate because of variance, and depending on the insurance company requirements, prior authorization can become a real barrier to care.

By requiring physicians to submit additional paperwork to prove that a patient requires an advanced therapy—sometimes still requiring the use of a fax machine—they are encouraging physicians to prescribe an older, possibly less effective option to avoid the prior authorization effort required by the insurer. Physicians often report having to dedicate several staff members full time to processing prior authorization forms for patients. And from the patient perspective, prior authorization requirements mean that accessing their prescription is delayed, which can lead to serious health consequences or complications, not to mention much more stress.

Legislative efforts to address this issue have focused on streamlining and bringing uniformity to prior authorization forms and appeals processes within states around the country.

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