Prior authorization criteria typically specify the diagnosis, the patient’s characteristics, test results, the treatments the patient must already have tried, and sometimes which specialists can prescribe. The prescriber’s office submits the request, often with supporting documentation, and the plan approves or denies it. Approvals are frequently time-limited and need to be renewed.
For patients and practices, prior authorization adds delay and paperwork. Some patients abandon treatment while waiting, and some prescribers choose a different medicine to avoid the process. For brands, the criteria can matter as much as formulary tier: two plans may both “cover” a product, but one with criteria so narrow that few patients qualify.
Manufacturers often support the process through hub services and field reimbursement teams, who help offices understand what each plan requires.
Criteria change without much notice, for your own product and for competitors. A tighter requirement found the week it is published can be addressed. One discovered months later, when prescriptions start being rejected, has already cost patients. That is why market access teams track criteria changes plan by plan.