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How PDL committee tracks prior authorization trends

Medicare & Reimbursement Advisor Weekly, August 12, 2009

The chart below illustrates the number of prior authorizations (PA) approved by month in Louisiana for its Medicaid program. The yellow line represents July–December 2005, the orange line covers all of 2006, and the purple line gives you a glimpse of the first half of 2007 through June. The reason for the low number of PAs in September 2005 is because of Hurricane Katrina. Louisiana lifted PA requirements generally across the board in September 2005, and once it reinstituted PA restrictions, the number of requests skyrocketed because “doctors were prescribing whatever drug they wanted without looking at the list,” says Germaine Becks-Moody, PhD, the state department of health and hospitals’ pharmacy program manager.

She notes that the P&T committee actually requested that the state track these data each month to help it understand the effect of its decisions. For example, if the committee opted to remove a drug from the PDL as of February 1, 2007, it might then look at the ensuing months to see whether physicians were switching to the PDL products or requesting PAs, Becks-Moody explains. In this case, you can see from the chart that PA requests increased in March and then again in April, “so the committee might ask us to look into the reason and could, in theory, adjust its decision if the trend continued,” she says.

Editor’s note: To read Louisiana’s April 2008 formulary, click here.

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