What kind of medications may require prior authorization under drug utilization management rules?

Prior authorization is a process used by health insurance companies, including United Healthcare, to determine whether a certain medication is medically necessary and appropriate for a given patient before it will reimburse the cost. Certain high-cost or high-risk medications often require prior authorization due to their impact on healthcare costs, potential for misuse or abuse, and the need for careful monitoring.

Medications that fall into this category may include specialty drugs, new therapies that require additional scrutiny, and treatments that could have significant side effects or interactions. By implementing prior authorization for these medications, insurance providers aim to ensure that patients receive the most effective treatment while managing healthcare resources responsibly. This helps to mitigate risks associated with high-cost drugs and ensures these medications are used appropriately.

In contrast, not all medications prescribed by physicians necessitate prior authorization, nor do all brand-name drugs or over-the-counter medications. For example, many generic medications are readily approved without this additional step, and over-the-counter medications generally do not require any form of authorization since they can be obtained without a prescription. Therefore, the focus on high-cost or high-risk drugs in the context of prior authorization aligns with the goal of promoting safe prescribing and financial responsibility in healthcare management.