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The debate about whether to require prior authorization (PA) before approving a therapy has been going on for years. “PA is the No. 1 tool payers use for managing large-cost products like biologics,” says Mark Zitter, at The Zitter Group in San Francisco. “The problem is that PA costs money. So there is this tension. The clear trend, though, is toward more management, especially with oncologics, and the tool that payers most talk about is PA.
“Payers value PA’s sentinel effect and so they approve most requests,” says Zitter. “What they fear if they remove PA is inappropriate requests and that a biologic would be used off label.”
As more payers buy into the clinical pathways model for cancer care, the decision to require PA becomes more complex. Says Zitter, “Payers can either require PAs, encourage them, or educate people about them, but, if they require PA, how would they enforce it? Either way, there’s a cost.”