Prior authorization and step therapy are different delays

Similar symptoms, different workflows

Prior authorization, special authorization, exception review, and step therapy can all produce a similar patient experience: the claim does not pay today. But they are not the same workflow. One may require a form. Another may require trial history. Another may require plan-sponsor approval. Another may require a public program decision before a private plan will consider the claim.

Calling everything “prior authorization” hides the next step. A better note identifies the actual pathway the plan is using.

Step therapy needs history

Step therapy is usually about evidence of previous therapy. The pharmacy record should not simply say that first-line therapy failed. It should capture what was tried, when it was tried if known, and whether the issue was ineffectiveness, intolerance, contraindication, or prescriber-directed change.

If the record does not contain that context, the claim may be paid today but become difficult to defend later.

Authorization needs ownership

When a prescriber must submit a form, the pharmacy should record that the prescriber was notified and what the patient was told. When the plan sponsor must authorize a limit, the patient may need to contact the employer or benefits administrator. When a public program decision is required first, the pharmacy should not treat the private plan as the first unresolved step.

Clear ownership prevents the claim from bouncing between pharmacy, patient, prescriber, and plan without progress.