News/Blogs
Every Patient, Every Fill: Managing Medication Access with Serve You Rx’s Prior Authorization Program
When managing healthcare benefits, peace of mind comes from knowing that your clients receive the best care precisely when they need it. At Serve You Rx®, we believe in saying “yes” and delivering on that promise with flexibility, transparency, and a commitment to your success. Our Prior Authorization (PA) program is a great example of how we make this happen every day.
Understanding Prior Authorization
Prior Authorization is a critical tool in the healthcare industry. It helps ensure that patients receive the most appropriate and effective medications. As the cost of specialty drugs continues to rise, particularly for mid-sized businesses, effective PA programs are even more essential in supporting the financial viability of health plans. By verifying the medical necessity and proper use of medications, PA programs safeguard patient health. They also help contain costs, giving you more time to focus on growing your business.
The Serve You Rx Prior Authorization Program: Tailored for Excellence
Our PA program is a comprehensive solution, covering over 800 medications known for their potential off-label use, increased toxicity, or costly waste. We work closely with healthcare providers to ensure that every prescription meets our stringent criteria before approval. Additionally, larger PBMs tend to rubber stamp PAs because they profit off drugs that are dispensed. Our interests align with the client’s, making sure their members are taken care of and they meet their cost-containment goals.
One of the standout features of our program is the quick turnaround time. We typically complete the PA process within three days, with most reviews completed in just one business day. This efficiency helps patients get their medications promptly, enhancing their satisfaction and loyalty to your health plans.
Success by the Numbers
Our PA program is not just about efficiency—it’s about results. For 2024, we’re proud to report a 67% approval rate for GLP-1 (glucagon-like peptide 1) agonists, a class of drugs that have recently been in the spotlight due to increased off-label use for weight loss. By implementing stricter criteria, we’ve successfully curbed unnecessary use. In doing so, we ensure these medications are available for those who truly need them.
Our program’s success also extends to specialty categories. Our average approval rate is 69%, but it can be even lower in certain specialty categories. These numbers reflect our commitment to providing clinically appropriate and cost-effective care.
PA Approval Rates for Top Specialty Categories
| Top Specialty Categories | PA Approval Rate |
|---|---|
| Anti-Inflammatory | 70% |
| Dermatology | 67% |
| Cancer | 78% |
| Multiple Sclerosis | 78% |
| Endocrine – Misc | 64% |
| Gastrointestinal | 72% |
| Asthma/COPD | 61% |
| Hematological – Misc | 56% |
| Cardiovascular – Misc | 54% |
Managing Specialty Costs without Compromising Care
Specialty medications, often life-changing for patients with chronic conditions like cancer or rheumatoid arthritis, can be incredibly costly. Our PA program incorporates evidence-based step therapy protocols, requiring a trial and failure of lower-cost alternatives before moving to high-cost specialty drugs. This approach aligns with best medical practices and helps reduce the spend on specialty medications.
For example, our PA guidelines for oncology drugs include a split-fill program, limiting the first two fills to a 15-day supply. This program prevents waste in cases where a patient stops medication early due to adverse events.
Recently, we analyzed our successful switch rate for high-interest categories. The switch rate includes our Prior Authorization and Step Therapy programs. It shows how often we successfully switched a member from a higher-cost medication to a clinically appropriate, lower-cost alternative.
Switch Rates for High-Interest Therapeutic Categories
| Therapeutic Category | Switch Rate |
|---|---|
| Antipsychotics | 100% |
| Asthma/COPD | 42% |
| Cancer | 53% |
| Dermatology | 48% |
| Diabetes | 64% |
| Gastrointestinal | 53% |
| Migraine | 53% |
| Neurologic | 75% |
| Ophthalmic | 68% |
| Respiratory – Misc | 50% |
| Sedative Hypnotics | 67% |
| Thyroid | 65% |
The Power of Electronic Prior Authorization (ePA)
Our Electronic Prior Authorization (ePA) system allows for real-time transmission of PA requests between providers and payers. The program is available to our clients as part of our clinical programs. This paperless, streamlined process speeds up approvals and reduces administrative burdens.
That means quicker access to medications and improved patient compliance.
Since launching our ePA program in 2023, we’ve seen tremendous benefits for both providers and patients. Quicker access to treatments, fewer rejected prescriptions, and enhanced satisfaction across the board are just a few of the advantages that make our ePA system a critical part of our PA program.
Looking Ahead: Expanding Our Impact
We’re excited about the future as we continue to innovate and refine our PA program. Our upcoming cardiometabolic weight loss program will integrate medication management with lifestyle support to improve outcomes for at-risk members. Expanding our ePA system with Auto Decision capabilities will further streamline the PA process. It will offer real-time approvals and denials and enhance efficiency and satisfaction.
Your Success is Our Goal
At Serve You Rx, our mission is simple: to help you succeed by taking care of your clients as if they were our own. Our Prior Authorization program is a testament to this commitment, offering unparalleled flexibility, efficiency, and clinical excellence. When we say ” yes, ” we mean it—because your peace of mind and your clients’ well-being drive us forward every day.
Let us help you build the health plans your clients deserve, with fewer surprises and more solutions that truly work. At Serve You Rx, we’re here to help you close business, keep your clients happy, and ensure that their healthcare needs are met with the highest standards of care and service.
Want to learn more about our cost-containing solutions?
Fill out the form below and discover the Serve You Rx difference.
About Serve You Rx®
Serve You Rx is a full-service pharmacy benefit manager (PBM) with unquestionable flexibility and an unwavering commitment to doing what's best for its clients. With a fervent focus on those it serves, including insurance brokers, consultants, third-party administrators, and their clients, Serve You Rx delivers exceptional service and tailored, cost-effective benefit solutions. Independent and privately held for nearly 40 years, Serve You Rx can implement new groups in 30 days or less and say "yes" to a wide variety of viable solutions. Known for its adaptability, quality, and client-centricity, Serve You Rx aims to be a benchmark for better client service.
