J Pediatr Gastroenterol Nutr. 2022 Oct 1;75(4):418-422.doi: 10.1097/MPG.0000000000003564. Epub 2022 Jul 15.

Stacy A Kahn ¹, Athos Bousvaros

Author information

¹Inflammatory Bowel Disease Center, Boston Children's Hospital, Harvard Medical School, Boston MA.

Abstract

Increasingly, in the United States, the prescribing of high-cost drugs has become a challenge for physicians and other practitioners. Such drugs are highly regulated by third-party payers (aka insurance), as well as pharmacy benefit managers. Not infrequently, a clinician prescribing a medication will have the payment for the prescription denied by the third-party payer, with the end result being a delay in getting a medically necessary medication to a patient. This article highlights the challenges involved in the prior authorization and denial process, with a focus on pediatric inflammatory bowel disease. The article reviews the role of pharmacy benefits managers in restricting access to drugs, and the reasons why denials of medically necessary medications may occur. The article also provides information on how to appeal denials, how to write a letters of medical necessity, and how to conduct a proper peer-to-peer review. Advocacy from patients and clinicians will be important, as we want to reform the process in the future.