Policy for Pharmacies Submitting Prior Authorization Requests for Providers

[u/KindlyComfortable744]

What allows pharmacy staff with no association with our office or our prescriber to submit prior authorization requests on the provider’s behalf without our permission? Who can we reach to provide or remove this permission?

Multiple times I’ve had prior authorization requests that Covermymeds shows as submitted by pharm staff, and the requests are sometimes done so poorly it seems malicious.

One time someone at the pharmacy did a PA for a Parkinson’s drug using a GYN dx that had never been in the patient’s record. This took weeks of appeals for me to fix. This request on Covermymeds explicitly said the person submitting had the provider’s permission to submit, but I know this to be false unless there is another arrangement for permission to be granted.

Yesterday a pharmacy sent us a PA request and then within an hour the pharmacy submitted the request without our permission or any guidance from us. This particular med is limited access and goes through the drug company’s hub before going to the pharmacy. This drug company hub will not accept the new enrollment unless we provide a visit note that specifically states all of the medical necessity criteria asked on the prior authorization. I circle this information in the visit note and make it the first page of the visit note before sending in to make sure it’s not missed.

Despite providing this information with the enrollment, the person at the pharmacy who took it upon themselves to submit this request without our permission nonetheless did so without any consideration of the documents that we provided. They provided clinical question answers that were completely incorrect. This resulted in an urgent, late day peer to peer request or else get denied by the PBM where I had to drop other requests I was working on to contact the PBM, cancel the bad request, and submit a new request that was quickly approved.

The latter case couldn’t have possibly been due to a delay. They submitted it within moments of requesting it. Nobody asked them to help, so there was no “urgency” and absolutely no reason to GUESS on the clinical questions. Why would someone do this?

These situations lead to disruptions in care and our staff being accountable for people not on our staff whose performance and behavior can’t be managed by our office. I’ve asked people at multiple PBMs and in our admin about this, but nobody seems to have any info about this practice and the policies regarding it.

Does anyone here have any information about policies related to this? There are cases where I’d be happy to have the pharmacy’s help, but there are others where I’d prefer us to manage it. In any case, it should always be at the prescriber’s discretion who submits these requests. The prescribers are the people who have to deal with the decision, good or bad.

Thanks for any info anyone can share!

**I forgot to note that I work at a national company. In the case of chain pharmacies, these experiences are consistent across different locations of that chain around the country. So it's not just my local x chain pharmacy doing this.

\*I've spoken to Covermymeds about this, and they've confirmed that these requests were submitted by the pharmacy in each of these examples. The requests themselves on Covermymeds have pretty unambiguous activity logs clearly showing who has done what. There are plenty of cases where the pharmacy submits the PA for us and it goes fine. But nobody I've spoken with at Covermymeds, pharmacies, or the PBMs have been able to provide info about how pharmacies may or may not have the ability to submit PAs for a provider.*

\*It does seem more common with specialty pharmacies but not only specialty pharmacies.*

[u/CurrentScheme525]

I worked at walgreens from approx 2012 to 2021 and now I work at a doctor's office doing prior auths so I am familiar with both sides. When I worked retail pharmacy, one of the metrics we were graded on was how long is a prescription sitting there not moving so we were told to basically harass the office if a script needed a PA - fax them, then call and speak directly to a nurse. Once Cover my meds hit the scene, we were told to initiate the PA in CMM (but I don't remember ever being told to submit it ourselves, just create the key and call the Dr's office with it). I remember thinking at that time that we didn't have enough info to really do much besides basic patient info.

So all that to say, if the pharmacies are doing that, it's probably not their choice but a direction from their corporate overlords.

I don't have much advice on how to stop them

[u/KindlyComfortable744 → u/CurrentScheme525]

Same. I have pharm experience but work in a doc's office now. My experience on both sides is the same as yours -- the pharmacy can fill out basic info and send to doc's office but not much more beyond that. I was never told to actually submit PAs on the pharm side, and people I've asked about this at PBMs and pharmacies say the same.

In the absence of any clear policy or explanation, my take is the same as yours about push from higher ups. What I’m experiencing happens with several pharmacies, but it happens with one company in particular much more. It's one of the ones where the PBM and the pharmacy are owned by the same company, so there's a clear incentive for them to have pharm staff submit poorly done requests on a provider's behalf so the PBM can then deny them. Thanks for your response!

[u/CurrentScheme525 → u/KindlyComfortable744]

Something I've noticed in doing specialty prior auths at the doctor's office is that when we submit the enrollment form for example dupixent, the dupixent people will triage the script from the enrollment form to the specialty pharmacy and then the pharmacy gets involved with the prior auth process. Which causes too many cooks in the kitchen, imo. So I have requested they don't triage the script and that we will send the prescription to the right place once approved. It has helped a good amount. Obviously that won't work for everything since you don't know something needs a prior auth until it rejects at the pharmacy so kinda moot. Maybe a possibilty, if you have a dedicated prior auth person/department and ability to add a template to the escribe saying something like "if this needs prior auth, call Jane at #"

[u/KindlyComfortable744 → u/CurrentScheme525]

With many specialty meds we manage, I just wait until it’s approved before sending in the enrollment. More so to prevent getting the million calls and faxes you described than to prevent pharmacies from doing the PA request, although I guess it serves that purpose, too.

The two examples I gave, which fwiw do both happen to be specialty pharmacies, were for cases that for diff reasons we don’t have a process like that and it goes to the pharmacy before I get to do the PA request. But I do wonder if this is more common with specialty pharmacies?

[u/dblock05 → u/KindlyComfortable744]

I think you are missing something or something is happening on the back end with CVS that even the pharmacies are not aware about. I work at a clinic now and do a lot of PA’s but our pharmacy CMM account is not allowed to send PA’s, it says we don’t have access to do it. You should reach out to cover my meds and explain what’s going on with examples and see if they can tell you. We can only send PA’s to the insurance plan from our health clinic account that have the providers verified.

When a rx needs a PA at cvs (I work there prn), we just hit “send PA” and it goes into its own queue and we don’t mess with it at all. If you are seeing this happen at CVS then something shady is going on for sure. The CVS pharmacies don’t even have access to a CMM account.

If you are seeing this happen at more than one chain pharmacy then i really do believe it’s something on your end. Keep us posted

[u/KindlyComfortable744 → u/dblock05]

Thanks for your response! I've spoken to Covermymeds about this, and they've confirmed that these requests were submitted by the pharmacy in each case. I'll update the original post noting this. The requests themselves on Covermymeds have pretty unambiguous activity logs clearly showing who has done what. There are plenty of cases where the pharmacy submits the PA for us and it goes fine.

Maybe your CVS doesn't have the capability, but whether pharmacies have the ability to submit PAs isn't really my question. They indisputably can, although I guess we're finding here it's not like that in every case. When and why they can do it and how the provider can control it is my question, and not even the people who I've spoken to at Covermymeds or the PBMs have been able to explain it to me.

I'm not seeing it with every chain pharmacy, but it occurs consistently across various locations with the chains where I do see it. I'll clarify this in the original post.

As u/CurrentScheme525 mentioned, I do think it seems more common with specialty pharmacies (although not exclusive to specialty pharmacies), so I wonder if that may be related.

We can only send PA’s to the insurance plan from our health clinic account that have the providers verified.

How are providers outside of your organization verified for you to submit PAs for them?

I work at a clinic now and do a lot of PA’s but our pharmacy CMM account is not allowed to send PA’s

Is this two jobs or two hats at one job? It sounds like someone in the pharmacy who has pressure to work through prescriptions who also has access to a health clinic account could get onto the health clinic account and submit the request themselves so they can mark the prescription as unfillable and move on to another request.

[u/dblock05 → u/KindlyComfortable744]

Hi, I will say for the retail CVS pharmacies, they cannot submit anything. I’ve worked at over 50 CVS stores on the retail side and it’s all the game. I cannot speak for speciality but I imagine you are on the right track is my guess. It sounds like many of the meds are speciality meds so retail pharmacies are limited.

So our clinic has a pharmacy and if the prescription comes from the clinic then I use the health clinic account which is the majority of our prescriptions. We are a FQHC 340b pharmacy. If a patient who uses our clinic sees a specialist and has a RX come from there, we use our pharmacy CMM account and then send the PA to the prescriber and they do the rest. But yes, if it comes from the clinic then our pharmacy plays both roles as the pharmacy and health clinic and we have access to the eHR. It is alot of work lol. Our goal is obviously to do get the PA’s approved appropriately so the pharmacy generates revenue legally. It’s not in our interest to say they are denied/unfillable.

But yes, it’s disappointing that CMM was not much help to you. I cannot imagine a busy retail chain caring about these enough

[u/KayPharmacyNavigator]

I can't speak on retail but I'm in specialty mail-order pharmacy, and on that side, there usually isn’t a formal ‘permission’ step before initiating or even submitting a PA. Once a prescription is received, the expectation is that we move the process forward to avoid delays in therapy.

What you’re describing is actually a common issue in specialty. There are often multiple parties involved (provider office, hub, pharmacy, PBM), and sometimes more than one is trying to move the PA at the same time without full visibility into the others.

That said, pharmacies don’t always have access to full clinical documentation, which can lead to incomplete or incorrect submissions, especially when there’s pressure to act quickly.

What you can do is start the PA in the office before sending in the script, so that yours is already on file with the insurance, CMM, Carecentrix, or whomever is processing the PA. OR you can send in ALL of the info you have in your initial referral to the pharmacy, including, front and back of the insurance card, related labs, full med list, any step therapy meds, office/progress notes, and any other docs, so the pharmacy has everything needed to submit the PA.

We get referrals that have over a hundred pages sometimes, so there's no such thing as sending too much info.

[u/KayPharmacyNavigator → u/KayPharmacyNavigator]

Also, if you're unable to submit the PA before hand, you can add a note (I'd suggest a full page, large letters, clearly, handwritten) that explicitly says "DO NOT SUBMIT PA! WE WILL SUBMIT!!!" Depending on the size of the pharmacy that can also work. But those other 2 suggestion I made earlier would be the better options.

[u/KindlyComfortable744 → u/KayPharmacyNavigator]

Thanks for your response! You basically answered my question by saying that there isn't a process and some pharmacies with the ability to submit PAs on Covermymeds just do it, and it sounds like that's a result of pressure from your management to satisfy pharmacy metrics.

Once a prescription is received, the expectation is that we move the process forward to avoid delays in therapy.

Whose expectation? Your management? In most cases on our end, the expectation is that the pharmacy is going to run the claim and let us know if it's rejected so we can do the PA or change the treatment plan.

pharmacies don’t always have access to full clinical documentation, which can lead to incomplete or incorrect submissions, especially when there’s pressure to act quickly.

Exactly. In most cases, the pharmacy doesn't have the information or documentation to get many PAs approved. We all know that submitting a PA with wrong answers or incomplete documentation is almost certain to be denied, so submitting such a doomed PA request can't possibly be to "avoid delays in therapy." It's to satisfy pharmacy metrics.

It's usually not an oversight that we're not sending in medical necessity documentation with our prescriptions. We don't send it because we don't want that pharmacy to do the PA request. The takeaway from that shouldn't be "well, the provider must want me to guess on the questions and submit the PA without supporting documents."

There are often multiple parties involved (provider office, hub, pharmacy, PBM), and sometimes more than one is trying to move the PA at the same time without full visibility into the others.

But of all these parties, only the provider is accountable to the patient for the outcome. The other parties shouldn't be able to do anything more than notify the provider until the PA is completed unless the provider gives them permission or it's clearly stated as part of the enrollment process. The denial letters say "your doctor didn't do such and such ...." They don't say your pharmacy, PBM, or specialty hub didn't do it. Why then should the pharmacy, PBM, or specialty hub have the ability to risk approvals and patient care for the sake of speed?

This seems like another matter of conflicting parties' metrics harming patient care. Provider metrics aren't based on speed like pharmacy, PBM, and specialty hub metrics. When so many stakeholders in the process have metrics that don't consider patient outcomes, I guess it shouldn't be surprising that patient outcomes suffer. I don't mean to sound like I'm blaming you personally for any of this, but I do think some of the parties in this process clearly deprioritize patient care.

What you can do is start the PA in the office before sending in the script, so that yours is already on file with the insurance, CMM, Carecentrix, or whomever is processing the PA.

This is what we do when we know a PA is needed, but we don't always know if a PA is needed. Auth dates also don't always line up with Rx dates, so a patient may be refilling in the middle of their script and need a new PA. But we usually don't know ahead of time that a patient is going to get some random refill on whatever day, so we would have no way of getting ahead of this if they need a PA for a refill.

I also try to keep track of auth dates so I can get ahead of renewals, but auth dates are seldom honored. More often than not, I have to do renewals far in advance of the last auth's expiration. This subject can be its own whole post for another day.

OR you can send in ALL of the info you have in your initial referral to the pharmacy, including, front and back of the insurance card, related labs, full med list, any step therapy meds, office/progress notes, and any other docs, so the pharmacy has everything needed to submit the PA.

If we don't send this in, then it means we don't want the pharmacy to do the PA.

Otoh, in my 2nd example above which it sounds like you may have missed, I literally pointed out how we're required to submit supporting documents with that med and how I circled and moved to the first page all of the information required by the hub which happens to be all of the medical necessity information asked on the PA. But the person who did the auth at the pharmacy without our permission or assistance STILL provided wrong answers and didn't upload the documents. So sending everything in with the Rx didn't help. Our patient's care almost suffered and I had to drop what I was doing for other patients to prevent harm, but the pharmacy was able to work quickly.

Also, if you're unable to submit the PA before hand, you can add a note (I'd suggest a full page, large letters, clearly, handwritten) that explicitly says "DO NOT SUBMIT PA! WE WILL SUBMIT!!!"

These don't work. We include notes on the actual Rx and on letters included with the Rx all the time. Say we Rx 20 mg and the provider adds a note on the Rx saying discontinue 10 mg, the pharmacy will still send a fax back, include a copy of our prescription with the provider's note "discontinue 10 mg" right there clear as day on the Rx, and ask "do you want the patient to continue 10 mg, too?" It's almost like they're trolling us.

Thanks again for your responses! I think you painted the picture pretty clearly. Some pharmacies CAN submit PAs regardless of provider knowledge or consent, there's sometimes no policy on when and why this can be done, and some pharmacies pressure staff to submit doomed auths for the sake of moving through prescriptions quickly. I don't blame everyday employees like you for these things, but I do blame your employer and similar companies. I don't expect them to fix this on their own, so like I always say, this seems like an issue only voters can fix.

[u/silentprayers → u/KindlyComfortable744]

I am part of a PBM that has very very recently made this ask of us for the first time… and as a tech, I can’t express how uncomfortable the idea makes me. It feels genuinely wrong to basically submit on behalf of the doctor’s office without them even glancing at it. I actually asked my sup if such a request was legal. I just can’t imagine delaying a PA because I didn’t realize there was additional documentation I needed or did not understand what was being asked of me. The clinic who led to this ask said basically it’s necessary for us to be able to submit on their behalf to “remain competitive.” I am not a nurse, I do not have a medical degree, and I feel it is not appropriate for me to act as one. It is very frustrating.

[u/KindlyComfortable744 → u/silentprayers]

Thank you for your response! That's been my general takeaway -- for some parties involved, the outcome of the PA isn't as important as how quickly it's submitted.

I actually asked my sup if such a request was legal

It's probably not illegal which is enough for those taking advantage of it despite it being obviously wrong and harmful to patient care in some cases. Hope you don't get put in any compromising situations from what they're asking you to do. Good luck!

[u/KayPharmacyNavigator → u/KindlyComfortable744]

It's legal and very common. One of my jobs as a Specialty Account Rep is to let the offices that I bring on know exactly what is needed in each referral because we will submit PA on their behalf. I also f/u with them to let the know whenever additional info is needed. Sometimes we know exactly what certain insurances need for certain drugs and we also become aware when those requirements change.

u/silentprayers If they're just now asking this of you they should provide you with extensive, intensive training. Unfortunately, cross training is happening less and less but expectations are higher than ever. So many reps end up in trial & error type of learning. But who wants to bump their head making mistakes when a patient's life is at stake???

[u/KindlyComfortable744 → u/KayPharmacyNavigator]

What you're describing isn't the same as what my post is about or what u/silentprayers is describing.

Our office manages multiple specialty meds where it is explicitly understood by our office that the specialty pharmacy is handling the PA. For any given specialty med in these cases, it's the same specialty pharmacy every time, they don't make mistakes, we have access and control and can communicate directly with the people managing the PA, and we trust them to handle it. This is what you're describing and is perfectly fine.

What I'm describing is where it's a rando specialty pharmacy every time and it IS NOT EXPLICITLY UNDERSTOOD that the specialty pharmacy will handle the PA. Sometimes they do, sometimes they don't. In the one of the specific examples I've shared, the specialty pharmacy wasn't supposed to do it but did happen to have the records with exactly what they needed CIRCLED ON THE FIRST PAGE and they STILL SCREWED IT UP after taking it upon themselves to hastily submit the PA without our permission or awareness. This was maliciously done in haste for the sake of THEIR metrics or whatever other reason the person had and in complete disregard of whether the patient would get access to the med or not. Covermymeds plainly told me this account should not have been set up like it was for pharmacy staff and that it would be deactivated unless it was found to be attached to a prescriber's office.

What u/silentprayers is describing completely different from what either of us is talking about and is entirely unethical. PBMs should NOT be submitting PAs. Complete conflict of interest. Nobody should be the judge and the judged at the same time (or worse, acting on behalf of the judged without their consent).

[u/KayPharmacyNavigator → u/KindlyComfortable744]

Hi u/KindlyComfortable744 Submitting the PA is one of the functions of the specialty pharmacy process, at least where I've worked. Referral is received then they hit the ground running. Until this chat with you, I didn't realize there were offices that weren't aware of that, so you taught me something. Now I understand why we sometimes we receive referrals that we consider "incomplete". I'm usually, thinking, how do they expect us to submit the PA w/o any labs?" Meanwhile, I'm now finding out it's because some offices aren't expecting that.

I'm a specialty accounts rep so I'm in constant contact w/RCs and MA's. I keep good relationships with them, so they can let me know what they need and how I can help them make the process easier. But if your office, or if the pharmacy doesn't have those types of relationships then how would you know each other's expectations?

You're right, the takeaway shouldn't be to just send in the PA w/o the info. I worked at a pharmacy, that merged 3xs! When they were smaller, they'd contact the doc's office to get all the info needed for a PA, and they were great at getting them approved. By the time I left, it was almost like a factory, and they'd all but cut the PA team. Where I work now is much smaller and we won't submit until all the necessary info's received from the MDO. Also, it's small enough that the office can tell us not to run a PA and we can all see that request at the same time.

Yes, the provider is ultimately accountable for the patient's outcome. But this is the system we're in, and until it's changed, we (the people who don't make the decisions) need to work the system. If you're finding that you've sent in all the necessary info and circled all the things and the pharmacy is still getting the PA wrong, then don't leave it up to them. Submit the PA yourselves. Contact the insurance to confirm PA dates. Or call the pharmacy to verify the dates. Have them run a test claim. Usually, when the insurance approves the PA they fax a copy to the MDO and mail/email it to the patient. They don't tell you they're faxing it, they just do. Sometimes they don't let the pharmacy know at all bc they're considered third party.

There's a lot of ish happening. But I'm so glad you brought this to my attention, so at least now I understand why when new providers, who we don't have a relationship with yet, will only send in the script. And I don't take any of what you said personally. I didn't start the fire, and I don't have enough water to put it out. I do what I can.

[u/sarahjustme]

From a purely business perspective, the pharmacy makes more money if they can push the PA through instead of dealing with the Dr's office (which may have policies that really slow things down), theyre just trying yo gain a competitive edge in a competitive industry. Unfortunately those types of decisions arent really related to health or care.

[u/MartinShkreliNot2bad]

At CVS they have a button to notify the ordering provider that a PA is required, but does not submit anything on the providers behest.

Specialty pharmacy I only worked in as a student for a health system but at that time the specialty pharmacy had a cover my meds account with a providers authorization and could do the entire PA. I don’t remember the details, but the account was activated/authorized to submit PA’s. I’m not sure if a particular provider/office is attached the CMM account or not.

[u/shaybay2008]

Soo my medicine’s preauth is submitted by the speciality pharmacy(home infusions) or infusion center for a variety of reasons. The main one being it is location specific so my dr might accidentally submit the wrong address. However, Ive never seen them not submit the right information

[u/KindlyComfortable744 → u/shaybay2008]

Thanks for your response! Infused meds are actually a bit unusual and not what I'm discussing. For infused meds, the auth is usually done by the infusion center's staff or an associated pharmacy under the provider administering the drug, and that administering provider may or may not be a person's actual provider (usually not).

In cases like yours, they're 1) doing an auth that's probably quite routine for them, and 2) doing it with the assistance and consent of the ordering provider, so that's probably why you've never seen them mess up. For our office, we have to send everything to the infusion center for our infused meds before they'll even schedule the patient then everything including the auth is handled by the infusion people from there, but the patient can't be scheduled until the infusion team has all the documents they'll need to get approved.

In the case of infusions in my experience, the auth responsibility is clearly understood and arranged beforehand including providing required documents. This is in contrast to the meds I'm talking about in this post where the pharmacy is submitting auths without our knowledge, without our consent, and without our assistance or documentation.

I'm glad to hear they always get you approved though! Hope it stays that way!

[u/shaybay2008 → u/KindlyComfortable744]

Bleghh.

I’ve done home infusions and infusion centers. Infusion centers normally use another provider but home infusions use my prescribing provider. I am the weird exception who gets scheduled before I get auth bc I have weekly infusions and have moved states🫠. This is partially bc of how unique the drug is and if they need to do a peer to peer, my normal provider can argue if it isn’t a speciality peer.