Prior Authorization Basics
This document explains why a patient needs a medication that requires insurance approval.
What is a prior authorization?
This biologic is commonly prescribed for moderate-to-severe psoriasis and psoriatic arthritis.
What is Skyrizi?
This class of medications reduces inflammation and itching.
What are topical corticosteroids?
This topical medication is often considered first-line for acne.
What is benzoyl peroxide?
This abbreviation stands for "prior authorization."
What is PA?
This information is almost always required before submitting a PA.
What are chart notes or clinical documentation?
his biologic targets IL-4 and IL-13 and is used to treat atopic dermatitis.
What is Dupixent?
Tacrolimus and pimecrolimus belong to this medication class.
What are topical calcineurin inhibitors?
This vitamin A derivative helps normalize skin cell turnover.
What is a topical retinoid?
This insurance requirement means trying a preferred medication before another one is approved.
What is step therapy?
Insurance companies often ask for this when a preferred medication has already been tried without success.
What is documentation of step therapy or treatment failure?
This biologic is approved for hidradenitis suppurativa.
What is Humira? (or Cosentyx depending on office preference)
This non-steroidal cream is commonly used for eczema and often requires a PA.
What is Opzelura?
This oral medication requires enrollment in the iPLEDGE program.
What is isotretinoin?
This form is completed when a patient has new insurance and needs continued biologic therapy.
What is a continuation prior authorization?
Missing this common piece of information can delay PA approval.
What is the patient's insurance information (or diagnosis code)?
Before many biologics are started, patients need this screening test for latent infection.
What is a tuberculosis (TB) test?
This vitamin D analog is commonly prescribed for psoriasis.
What is calcipotriene?
This topical antibiotic is commonly paired with benzoyl peroxide to reduce resistance.
What is clindamycin?
This pharmacy benefit manager is one of the largest in the U.S.
What is Express Scripts? (Also acceptable: CVS Caremark or Optum Rx.)
If a PA is denied, this is often the next step.
What is an appeal?
Insurance companies often require patients to fail these before approving a biologic.
What are preferred therapies or step therapy medications?
This medication class should generally not be used continuously on thin skin because of the risk of atrophy.
What are topical steroids?
This is the reason benzoyl peroxide is combined with topical antibiotics.
What is preventing antibiotic resistance?
This is the amount of time many PA approvals remain valid before renewal is needed.
What is one year? (Varies by insurance.)