Health plans frequently impose utilization management tools, such as prior authorization and step edits, in their prescription drug coverage policies. Their goal is to curtail inappropriate use and contain costs, but the policies can create barriers to appropriate care. The American Medical Association, along with more than 50 clinical and professional health care organizations, have published key principles for utilization management with the goal of reducing “the negative impact they have on patients, providers and the health care system.” Among the principles is the need for transparency in prior authorization requirements, criteria, and rationale.
