In turn, this allows ODS to determine whether the medical necessity request for the drug meets the specific coverage criteria for that specific plan. Direct to Consumer Advertising Pharmaceutical manufacturers heavily advertise most new drugs. Patients may request and often demand certain prescriptions from their physicians that may not be approved for their specific indication. The ODS prior authorization procedure also provides a reduced pressure mechanism for a physician to deny a prescription for a patient for whom the physician does not think the prescription is appropriate or will not work and yet the patient demands the prescription. The prior authorization is a tool for ODS to receive information from the prescribing physician to ensure that employer - purchased drug coverage parameters are being met.
Prior authorizations are a way of managing plan costs on behalf of the employer.
Often times, physicians are not aware of the price differences between different drugs and the prior authorization mechanism assists ODS members in getting the most cost effective medications. The prior authorization process is used to determine medical necessity, ensure patient safety and assist in administrating employer benefits appropriately. Call share specialists must be in-panel with the patient s plan in order to receive the higher level of benefits.