What a Simple Drug Prior Authorization Policy Looks Like

Why It Matters

Drug prior authorization (PA) policies sit at the intersection of evidence-based medicine, health plan resource management, and patient access in pharmacy. A simple drug prior authorization policy isn’t just a coverage filter—it’s a clinical tool that promotes appropriate use of drugs while minimizing confusion for prescribers, patients, and health plan reviewers. Simplicity is the key to wider awareness.

This Post Is For:

  • Health plan and PBM decision-makers seeking to improve policy clarity
  • Brokers and access consultants who need usable references
  • Pharma and biotech specialists aligning approach for coverage optimization
  • Clinicians navigating utilization management (UM) criteria

Example Drug: Ebglyss™ (lebrikizumab-lbkz)

Indication Label (Prescribing Information)

“Ebglyss is indicated for the treatment of adults and pediatric patients 12 years and older with moderate-to-severe atopic dermatitis who weigh at least 40 kg and whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable.”

Building a Simple PA: Key Principles

1. Be Explicit with Criteria

A simple drug prior authorization policy avoids implied or overly interpretive language. It clearly states:

  • Diagnosis and ICD-10 code
  • Age and weight thresholds
  • Required prior therapies, including duration or failure criteria
  • Relevant labs or severity scores (with objective cutoffs)
  • Route of administration (e.g., subcutaneous vs IV)

2. Align with Guidelines and the Label

Simple PAs should track closely to:

  • FDA-approved prescribing information
  • National clinical guidelines (e.g., AAD, GINA, ACR)
  • Clinical consensus in evolving areas (real-world evidence, off-label use, label expansions)

Bonus: Consider flagging which criteria are linked to rebate eligibility to maximize transparency and value communication.

3. Keep It Human-Readable

Avoid unnecessary jargon. When complex terms (e.g., “interleukin-13 antagonist”) are required, provide brief definitions or context.

Goal: A frontline prescriber or pharmacist should be able to scan and understand in under 30 seconds.

4. Design for Portability

Use consistent formatting for ease of review. Enhance clarity with:

  • Tagging (e.g., diagnosis, step therapy, duration)
  • Color-coding by category
  • Metadata: source, last review date, contact information

Bonus: What to Include in a Simple PA Footer

Include a compact metadata box for:

  • Policy relevance (plan/formulary context)
  • Last review or revision date
  • Authorization duration (e.g., 6 months initial, 12 months renewal)
  • Dynamic or live compliance tag (annual review)
  • Internal strategy notes (e.g., monitored for step therapy fraud, waste or abuse, preferred tiering, formulary placement)

About Andrew

Hey! I’m Andrew Gilberto Vargas, a pharmacist and writer. I reflect on concepts that shape pharmacy benefits, drug access, leadership and meaning-making. Always curious, always learning.

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