Focus on Managed Care Pharmacy

(M1) Prior Authorization Criteria: Looking Beyond Clinical Trial Populations

Wednesday, March 22, 2023

8:45 AM – 10:00 AM

Location: 301AB

ACPE UAN:0233-0000-23-012-L04-P | Contact Hours: 1.25 | Activity Type: Knowledge-based

Faculty(s)

Heather Odem, PharmD (she/her/hers)

Director of Pharmacy
UnitedHealthcare Community & State- Mississippi
Ridgeland, MS
Richard Ogletree, PharmD

Pharmacy Director
Alliant Health Solutions
Ridgeland, MS

Moderator(s)

CR

C.E. (Gene) Reeder, RPh, PhD

Professor and Director of Outcomes Research
University of South Carolina College of Pharmacy
Columbia, South Carolina

New medications often require prior authorizations (PA), but how is PA criteria determined? Most PA criteria is based on the clinical trial, using specific numerical values to determine effectiveness. Many often take for granted the complexities of assigning this PA criteria, hence the importance of understanding the ‘why’ and taking into consideration the inclusion and exclusion criteria from the clinical trials.

This session will discuss relatively new medications and common PA criteria often used as faculty explore criteria based on pivotal trial populations/outcomes compared to potential patient benefit. Faculty will share real-life examples and research results.

Learning Objectives::

At the completion of this activity, participants should be able to:

Determine inclusion/exclusion criteria developed for the benefit of a pivotal trial itself.
Recognize the differences between trial-focused and patient-focused baseline and outcome data employed in prior authorization criteria.
Explain how to use a patient-focused approach to develop prior authorization criteria.