As a part of ongoing efforts to support patient safety, Independence continues to apply prior authorization on select medications that are deemed to be high-risk in patients at least 65 years of age. These high-risk medications (HRMs) are derived from the American Geriatrics Society Beers Criteria^®.¹

Commonly prescribed HRMs include:

• butalbital-containing products for headaches;
• zolpidem for insomnia;
• glyburide for diabetes;
• cyclobenzaprine and carisoprodol for musculoskeletal conditions.

Part of the prior authorization criteria requires written or verbal documentation that the risks versus benefits have been assessed, even if for continuation of therapy. This is because as members age, physiological changes can affect pharmacodynamics of drugs, even if taken for a long period of time. These changes can leave members more susceptible to side effects of the drug, leading to adverse events such as loss of balance and impaired cognition. The prior authorization serves to ensure that the medications are for appropriate uses, and that safety has been assessed for new start of therapy and continues to be assessed at least yearly for continuation of therapy.

Tips for successful prior authorization submissions

To reduce the administrative burden on your offices, Independence encourages the following office staff training opportunities to support a more efficient prior authorization process:

• Encourage your staff to fully complete and submit prior authorization forms, including a clear response to whether a risk-benefit assessment has been completed prior to prescribing the medication.
• Provide clarity to your staff on where to find support in the patient chart notes for where the prescriber assessed the risk-benefit of the medication.
• Reinforce that from a prescriber standpoint, if a prescription is being renewed or continued, then it could be implied that the risks have been considered and benefits outweigh the risks. This is dependent on the prescriber and the workflow that is established in each practice.
• Utilize electronic prior authorization (ePA) as often as possible. These services are offered through CoverMyMeds^® and SureScripts. All prior authorization forms and ePA platforms can be found on the FutureScripts^® website.

Learn more

If you have any questions regarding the prior authorization process, please call FutureScripts, our pharmacy benefits manager, at 1-888-678-7012.

¹American Geriatrics Society Beers Criteria Update Expert Panel: American Geriatrics Society 2019 updated AGS Beers Criteria^® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019; 67(4):674-694. Available from: https://qioprogram.org/sites/default/files/2019BeersCriteria_JAGS.pdf

FutureScripts and FutureScripts Secure are independent companies that provide pharmacy benefits management services.