CASP Module 6, Section 2: Prior Authorization and Peer-to-Peer Strategies
Module 6: Patient Access & Benefit Navigation

Section 6.2: Prior Authorization and Peer-to-Peer Strategies

Transforming the Prior Authorization (PA) process from a clerical task to a clinical argument. Crafting compelling appeals and mastering the peer-to-peer review.

SECTION 6.2

Prior Authorization and Peer-to-Peer Strategies

The Pharmacist as Clinical Advocate: Building an Indisputable Case for Coverage.

6.2.1 The “Why”: Reframing the PA from Burden to Battle Plan

As a pharmacist, the phrase “Prior Authorization” (PA) likely incites an immediate, visceral reaction of frustration. In the high-volume retail world, a PA is a roadblock. It’s a rejection. It’s an unexpected halt in your workflow, a “call the doctor” message that creates friction, delays, and patient dissatisfaction. Your job has been to identify this barrier and get it off your plate as quickly as possible so you can move to the next prescription. This is a workflow built for survival, and it is entirely appropriate for that setting.

In specialty pharmacy, this entire mindset must be inverted. The Prior Authorization is not the exception; it is the default process. It is not a “rejection” in the traditional sense; it is the standard, required first step for every new specialty prescription. The PBM or health plan is not “denying” the drug; they are formally requesting, “Please submit the clinical case file for our review.”

This mental shift is the most important leap you will make in this module. A PA is no longer a clerical burden to be “handled.” It is a clinical argument to be won. The stakes are profoundly different. A PA delay for atorvastatin is an inconvenience; a PA denial for a new multiple sclerosis therapy can mean a six-week delay, a permanent loss of patient adherence, and a complete breakdown of the care plan. A poorly executed PA can lead to thousands of dollars in uncovered claims for your pharmacy or unmanageable debt for the patient.

As a Certified Advanced Specialty Pharmacist (CASP), you are the chief strategist for this process. You are no longer a “paper-pusher” or a “fax-sender.” You are the clinical case builder. You are the legal mind who collaborates with the provider (your “co-counsel”) to assemble an airtight, evidence-based argument that makes an approval the *only* logical outcome. Your deep knowledge of pharmacology, therapeutics, and clinical guidelines makes you uniquely qualified for this role. You are not just facilitating a PA; you are managing it, strategizing it, and owning it from submission to approval. This section will teach you how to build an indisputable case, every single time.

Pharmacist Analogy: The Invoice vs. The Legal Brief

This is the core concept that separates retail PA from specialty PA.

In your retail practice, a prescription claim is an Invoice. You send a bill (the claim) to the payer. The payer’s computer reads it and either pays it (a “paid” claim) or rejects it (a “PA required” claim). A PA rejection is simply a “disputed invoice.” Your job is to send the invoice back to the provider’s office (the “accounts department”) for them to sort out. It’s fast, transactional, and appropriate for the context.

In specialty pharmacy, a Prior Authorization is a Legal Brief you are preparing to submit to a court. The payer is the judge. The patient is your client. The provider is your co-counsel. The payer’s “Medical Policy” is the law (the “rule book”).

Your new role as a CASP is to be the lead paralegal and case strategist. You would never just throw a stack of random papers at a judge and hope they find the evidence. Instead, you:

  1. Acquire the Law (The Medical Policy): Your first step is to get the “rule book.” You find the payer’s exact medical policy (e.g., “Policy 5.2.1 for Use of TNF-alpha Inhibitors”). This is the “answer key.”
  2. Gather Discovery (The Evidence): You work with your co-counsel (the provider) to gather *all* the evidence: chart notes, lab results, radiology reports, and records of past medication failures.
  3. Write the Legal Brief (The Letter of Medical Necessity): You don’t just “submit the PA.” You write a compelling, one-page summary. This brief (the LMN) cites the law (“Per your own Policy 5.2.1, which states a patient must fail methotrexate…”), presents the evidence (“…we have attached chart notes from 10/24/25, page 5, showing the patient failed methotrexate…”), and makes a logical conclusion (“…therefore, the patient meets your stated criteria, and we request approval.”).
  4. Prepare for the Hearing (The Peer-to-Peer): If the “judge” (the payer’s Medical Director) still denies the case, you prepare your co-counsel for the “appeal hearing” (the P2P). You give them a one-page “slam dunk” summary of the facts so they can win the argument in under 5 minutes.

An invoice-filler submits a form. A legal strategist builds an unassailable case. This section is your “law school” for winning these cases.

6.2.2 Deconstructing the Denial: The “Anatomy” of a Rejection

In retail, a PA rejection is a simple `NCPDP 75` code. In specialty, a denial is a formal letter (the “Explanation of Benefits” or “Notice of Adverse Benefit Determination”) that provides the *exact* reason for the denial. This reason is your roadmap for the appeal. You must learn to read these denials not as a “no,” but as a “not yet, because you failed to provide…”

Your first action upon receiving a denial is to get the formal denial letter. This letter is your opponent’s entire strategy, revealed. It will almost always fall into one of these categories.

Masterclass Table: The “Real” Reasons for a PA Denial
Denial Type / Payer Language What It *Actually* Means How to Build Your Appeal (Your “Rebuttal”)
Step Therapy (ST) / “Prerequisite Failure” “Your case is clinically valid, but the patient has not tried and failed our preferred (cheaper) drug(s) first.” This is the #1 most common denial. Your *only* path to victory is to prove one of two things:
1. Failure: “We agree. The patient *did* try your preferred drug, [Drug Y], and it failed. See attached chart notes from [Date] showing inadequate response.”
2. Contraindication (CI): “We agree, but the patient cannot take [Drug Y] because they have a documented contraindication (e.g., ‘Patient has a history of DVT, which is a black-box warning for Xeljanz’). Therefore, the step is clinically inappropriate.”
“Missing or Insufficient Clinical Information” “You didn’t prove your case. You just sent a form. You didn’t send the chart notes, labs, or diagnostic reports we need to check the boxes in our policy.” This is a “procedural” denial. It’s your fault, not the payer’s.
Rebuttal: Do not just resubmit the same form. Call the payer, ask *exactly* what was missing (“Did you need the TB test? The H&P?”), and resubmit with a Letter of Medical Necessity (LMN) that points the reviewer to the *exact page* of the new attachments.
“Not Medically Necessary” This is the most dangerous and vague denial. It means: “You sent us information, but it did not meet the criteria in our medical policy.” This requires a true clinical argument.
1. Find the Policy: Get the payer’s medical policy *immediately*.
2. Identify the Mismatch: (e.g., “The policy requires a DAS28 score > 5.1; the patient’s score was 4.9.”)
3. Formulate the Argument: “While the DAS28 was 4.9, the patient *also* has 12 swollen joints and new erosions on X-ray, indicating severe, progressive disease that the DAS28 score alone fails to capture. We request an exception…” This *will* require a Peer-to-Peer.
Dosing / Quantity Limit (QL) Mismatch “We agree the drug is necessary, but the *dose* you prescribed (e.g., 4 pens for a loading dose) is not our standard QL (2 pens/month).” This is a *separate* PA. You need a “Dosing Exception” or “QL Override” PA.
Rebuttal: Your LMN must cite the FDA-approved Package Insert (PI). “Per the FDA-approved PI for [Drug Name], the required loading dose is [X]. We are requesting this one-time QL override, which is in line with the manufacturer’s labeling.”
“Plan Exclusion” / “Non-Formulary” “This drug is not on our list at all. We have a contract with its competitor, [Drug Y].” This is the hardest fight. You must prove that *all* preferred options are clinically inappropriate.
Rebuttal (The “All-Fail”): “We are requesting a Formulary Exception. The patient cannot take the preferred [Drug Y] due to [CI], and has already failed [Drug Z] (see notes). Therefore, the requested drug is the *only* remaining clinically appropriate option for this patient.”

6.2.3 The “Pre-Game”: Assembling Your Clinical Case File Before You Submit

You will lose 90% of your PA battles if you “submit and pray.” A CASP-level expert wins the PA before they ever submit it by building an unassailable case file. This is the “discovery” phase of your legal brief. You must become a master at “shopping” the provider’s EMR for the exact “golden nuggets” of data the payer needs to see.

Never, ever just attach the last 50 pages of chart notes. This is the #1 mistake. The payer reviewer is a nurse or pharmacist reviewing 100 cases a day. They will not hunt for your evidence. You must do it for them. Your job is to be the world’s best “executive assistant” for that reviewer, making their job of saying “yes” as easy as possible.

The CASP PA “Case File” Checklist

Before you open CoverMyMeds or pick up a fax machine, you *must* have this file built.

PA Case File: Required Components

  1. The “Cover Sheet” (Your LMN)

    This is your one-page summary. We will detail this in the next section, but this is your “legal brief” that guides the reviewer through your evidence.

  2. The “Rule Book” (The Payer’s Medical Policy)

    You must find and download the payer’s *exact* medical/pharmacy policy for this drug. You can find this on their provider portal (Availity, Optum, etc.) or by Googling “[Payer Name] [Drug Name] Medical Policy.” This is your “answer key.” Your LMN must be written to answer *every single criterion* in this document.

  3. The “Evidence Locker” (The Clinicals)

    This is the appendix to your LMN. You must pull *only* the relevant documents. A 5-page submission with the 5 right pages is infinitely better than a 50-page submission.

    • H&P / Consult Note: The note that *establishes the diagnosis*.
    • The “Proof of Diagnosis” Lab/Report: The specific lab (e.g., positive ANA), radiology report (e.g., MRI showing plaques), or test (e.g., PFTs) that confirms the diagnosis per the policy.
    • The “Proof of Failure” Notes (for Step Therapy): This is the *most critical* piece. You need the *actual chart note* that says, “Patient has been on methotrexate, is still having 10 swollen joints, recommend escalating therapy.” A simple med list is *not* proof of failure.
    • The “Baseline Safety” Labs: The required labs before starting therapy, as mentioned in the PI (e.g., TB test, Hepatitis B panel). This proves to the reviewer that the provider is practicing safely and the patient is an appropriate candidate.

6.2.4 Writing the “Letter of Medical Necessity” (LMN): The Pharmacist’s Thesis

Standard PA forms (like those on CoverMyMeds or Surescripts) are designed to be fast, but they are terrible at telling a story. They are a series of disjointed clinical checkboxes. This is why a denial for “missing information” is so common. The reviewer couldn’t connect the dots.

The Letter of Medical Necessity (LMN), also called a “Letter of Appeal,” is your tool to connect the dots. It is a one-page cover letter that you attach to *every* PA submission. It is your “legal brief” that walks the reviewer through your argument and points them to the exact evidence in your attachments. This single document will increase your approval rate more than any other tool.

Your pharmacology and counseling skills are perfect for this. When you counsel, you take complex information (how a drug works, side effects, interactions) and synthesize it into a simple, clear story for the patient. The LMN is the exact same skill, but your audience is the payer’s clinical reviewer.

The “IRAC” Method: Building a Bulletproof LMN

A great LMN follows the same structure as a legal argument. IRAC stands for Issue, Rule, Analysis, Conclusion. This framework is logical, professional, and incredibly effective.

Part 1: The Header

RE: [Patient Name, DOB, Member ID]

FROM: [Dr. Provider’s Name, NPI / Your Name as Clinical Pharmacist]

DRUG: [Drug Name, Dose, J-Code/NDC]

DIAGNOSIS: [Diagnosis, ICD-10 Code]

Part 2: The Argument (IRAC)

[I]SSUE: “To the Clinical Reviewer, we are requesting authorization for [Drug Name] for our patient, [Patient Name], for the treatment of [Diagnosis]. This patient has severe, active disease that has not responded to previous therapies.”

[R]ULE: “Per your medical policy [Policy # or Name, e.g., ‘Policy 5.2.1 for TNF Inhibitors’], coverage criteria for [Drug Name] include:

  1. A confirmed diagnosis of [Diagnosis] by a specialist; and
  2. A trial and failure of at least one conventional therapy (e.g., methotrexate); and
  3. A current TB test and Hepatitis B screening.“

[A]NALYSIS: “This patient, [Patient Name], meets all of your stated criteria for coverage:

  1. Criterion 1 (Diagnosis): Patient was diagnosed with [Diagnosis] by Dr. [Specialist] on [Date]. (See attached H&P, page 2).
  2. Criterion 2 (Failure): Patient was trialed on methotrexate 25mg/week from [Date] to [Date]. This therapy failed, as evidenced by continued high disease activity (DAS28 score of 5.3) and 12 swollen joints. (See attached progress note from [Date], page 5).
  3. Criterion 3 (Safety): Patient has a negative TB test (dated [Date]) and a negative HBsAg (dated [Date]). (See attached lab report, page 8).

[C]ONCLUSION: “As demonstrated, this patient meets all published coverage criteria for [Drug Name] as outlined in your own medical policy. We request authorization for [Dose/Frequency] for 12 months. Please see the 8 pages of attached clinicals, with relevant data highlighted. I am available for an immediate Peer-to-Peer review to discuss this case at [Your Direct Phone Number].”

Sincerely,

[Your Name, PharmD, CASP, on behalf of Dr. Provider]

This LMN is now the “Table of Contents” for your submission. You have made it *impossible* for the reviewer to deny for “missing information.” You told them the rule, showed them how you meet the rule, and told them *what page* to find the proof on. This is how you win.

6.2.5 The Appeal: What to Do When They Still Say “No”

Sometimes, even a perfect submission gets denied. The reviewer may have missed your evidence, or the case may fall into a “gray area” of the policy. A denial is not an end. It is simply the *start* of the formal appeals process. Your LMN was the opening argument; the appeal is your rebuttal.

Step 1: The Formal (Written) Appeal

The first step is a formal written appeal. This is your LMN, but with an angrier, more direct introduction. You must address their *specific reason for denial* head-on.

Example Appeal Introduction (for a Step Therapy denial):

“RE: APPEAL for [Patient Name] – Denial ID [Denial #]

“To the Appeals Department, we are in receipt of your denial dated [Date] for [Drug Name]. The stated reason for denial was ‘Failure to meet Step Therapy requirements (trial of Drug Y).’ This denial is incorrect and must be overturned. As documented in our original submission, the patient has a *clear, documented contraindication* to your preferred agent, [Drug Y]. Per the patient’s H&P (page 2), she has a history of DVT. [Drug Y] carries an FDA black-box warning for thrombosis and is therefore clinically inappropriate and dangerous for this patient. Per your own policy’s ‘Exceptions to Step Therapy,’ a documented contraindication grants an exception. We are re-attaching the clinical notes and demand an immediate review and reversal of this improper denial.”

This appeal is no longer just presenting evidence; it is challenging their ruling using their own rules and federal guidelines (the FDA label).

Step 2: The Peer-to-Peer (P2P) Review

If the written appeal is denied (or as an alternative to it), the payer will offer a “Peer-to-Peer” (P2P) review. This is a scheduled phone call between your prescriber and the payer’s Medical Director (who is also an MD). This is the “appeal hearing” in front of the judge.

Your provider is busy. They have 5 minutes between patients to make this call. They will fail if they are not perfectly prepared. This is where you, the CASP, become the “P2P Coach.” You must create a “Slam Dunk Prep Sheet” that gives your provider the *exact* 3 sentences they need to win the appeal.

The P2P is a Trap! (Unless You Are Prepared)

Your provider will often walk into this call assuming it’s a friendly, collegial “chat between doctors.” It is not.

The payer’s Medical Director is not their friend. They are a trained employee of the insurance company. Their job is *not* to “do what’s best for the patient”; their job is to uphold the medical policy. They are an expert in their policy, and they are trained to win arguments.

  • How Providers Lose: They get emotional. (“My patient is suffering! You have to approve this!”) This is an *instant loss*. The Medical Director will say, “I understand your frustration, Doctor, but the policy states…”
  • How Providers Lose: They get sidetracked. The MD will ask, “I see you didn’t try Drug Z. Why not?” The provider, unprepared, will stumble.
  • How Providers Lose: They argue medicine. (“I’m the specialist, I’m at the bedside, and this is the right drug.”) The MD will respond, “Your clinical opinion is respected, but it is not grounds for an exception to a policy you contractually agreed to.”

How You Win: You win by using the payer’s own policy against them. The *only* way to win is to prove that you *do* meet the policy, or that you meet a *specific exception* within the policy. You must make it easier for the MD to say “yes” (because you meet the rules) than to say “no.”

6.2.6 Masterclass: The Pharmacist’s “Peer-to-Peer Prep Kit”

You must assume your provider has 60 seconds to review your prep sheet before dialing the number. It must be a “One-Page Slam Dunk.” It should be attached to the top of their EMR task, printed and handed to them, or (ideally) you are on the phone with them 2 minutes before the call, reading it to them.

Template: The “P2P One-Page Slam Dunk” Prep Sheet

P2P PREP SHEET: URGENT

[Date of Call]

Patient: Jane Doe, DOB 1/1/1965

Payer: Aetna (Call-in #: 1-800-XXX-XXXX, Ref #: 12345)

Drug: Skyrizi (risankizumab)

Denial Reason: “Step Therapy Failure Not Met. Patient has not trialed and failed Humira.”

YOUR 3-POINT “SLAM DUNK” ARGUMENT:

Doctor, this is a simple “policy exception” argument. You only need to make these three points:

  1. Point 1 (Acknowledge & Reframe): “Hello Dr. [Payer MD], I’m calling about Jane Doe’s Skyrizi denial. The denial states we didn’t meet the Humira step. This is correct, but we are requesting an exception based on a documented contraindication.”
  2. Point 2 (The Evidence): “My patient has a diagnosis of Congestive Heart Failure, Class III, which is documented in her cardiology notes. As you know, TNF-alpha inhibitors like Humira have an FDA black-box warning for worsening or new-onset heart failure and are contraindicated in this patient.”
  3. Point 3 (The Close): “Per your own medical policy for Psoriasis [Policy #4.5.6], an exception to Step Therapy is granted for ‘a documented contraindication to the preferred agent.’ This patient meets that exception. I am asking you to overturn this denial based on your own policy and the clear clinical safety risk.”
IF THEY PUSH BACK:
  • If they say: “Why not try Otezla?”
  • You say: “Otezla is not appropriate given her severe plaque burden (PASI score of 22) and history of depression. Skyrizi is the most appropriate agent.”

Stick to the contraindication. That is the winning argument.

6.2.7 The Pinnacle: The Pharmacist-Led P2P Review

In many modern specialty pharmacies and health systems, providers “deputize” their clinical pharmacists to handle P2Ps. This is the new frontier and the ultimate expression of your role as a clinical advocate. Why? Because, frankly, you are better prepared to win this specific type of argument than a busy provider.

  • You are not rushed.
  • You are an expert in reading and quoting medical policies.
  • You are an expert in pharmacology (e.g., “the CI for Xeljanz”).
  • You built the case file, so you know exactly where the evidence is.
  • You are not emotionally invested and can remain professional and logical.

The Payer’s Medical Director is often *relieved* to speak to a CASP. You are speaking their language. You are not yelling. You are presenting a logical, evidence-based argument that references *their own rules*. You are not asking them to “break the rules” for your patient; you are demonstrating how your patient *meets the rules*. You are giving them the clinical and legal justification they need to check the “Approved” box and move on. This is the highest form of clinical advocacy.

Your Script for the Pharmacist-Led P2P

You: “Hello Dr. [Payer MD], my name is [Your Name], I am the clinical specialty pharmacist at [Your Pharmacy/Clinic], calling on behalf of Dr. [Provider] regarding the denial for Jane Doe, reference number 12345. Dr. [Provider] has designated me to present the clinical case for this appeal.”

Payer MD: “OK, Doctor, what do you have?”

You: “Thank you. I see the denial was for a failure to meet the Step Therapy requirement for Humira. I’m calling to request an exception based on a clear contraindication. Our patient has NYHA Class III CHF, and as you know, Humira carries a black-box warning for this condition. Per your own medical policy 4.5.6, this meets the criteria for an exception. I have the cardiology notes available if you’d like to review them. Can we proceed with overturning this denial?”

You have just won the appeal in 30 seconds. You were professional, cited the policy, and presented an irrefutable clinical fact.

6.2.8 The “After-Action”: Tracking, Metrics, and Re-Authorization

Winning the PA is not the end. It is the beginning. A PA is a “permission slip” with an expiration date. Your final responsibility is to manage the lifecycle of that authorization.

Masterclass Table: Building a PA Tracking Dashboard

You must move your PA queue from a “pile of faxes” to a managed, professional workflow. A good PA tracking system (in your pharmacy software or a spreadsheet) must include these fields.

Field Example Why It Is Critical
Patient / Drug / Payer Doe, Jane / Skyrizi / Aetna Basic Identification.
PA Status Pending, Approved, Denied The high-level status.
PA Sub-Status / “Owner” “Submitted – Awaiting Payer,” “Pended – Need Labs,” “Denied – Awaiting P2P,” “Approved” This is the *actionable* status. Who is responsible for the next step?
Submission Date 10/24/2025 The “timer” has started.
Anticipated Response Date 10/27/2025 (Urgent) or 11/07/2025 (Standard) This is your “follow-up” date. If you haven’t heard by this date, *you* must call *them*.
Authorization # G12345678 The “golden ticket.” This must be on the final claim.
PA Expiration Date 10/23/2026 The “Time Bomb.” This PA is good for 12 months.
“Flag for Re-Auth” Date 08/23/2026 This is the CASP-level field. You set a reminder for 60 days before expiration. This gives you ample time to gather new clinicals and submit the re-authorization so there is *no gap in therapy* for the patient.

By managing this process, you transform the pharmacy’s role. You are no longer a passive participant in the PA process; you are the active, central manager of the patient’s entire clinical and financial journey. You own their access, you forecast their barriers, and you build the arguments that ensure their therapy is never interrupted.