📋 Prior Authorization

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📋Module 5 · Slide 15

Authorization Requirements — The Golden Rule

Here's the golden rule of home infusion: no authorization, no payment. It's that simple. Payors require prior auth for high-cost specialty drugs to confirm the therapy is clinically appropriate and that the patient has tried less expensive options first.

⚠️ Non-Negotiable Rule

Retroactive authorizations are almost never granted. If we start a patient without an auth, we're taking a huge financial risk. This is non-negotiable. Every sales rep needs to understand and respect this process — and communicate it clearly to referral sources.

Why Payors Require Prior Auth

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Clinical Appropriateness

Confirm the therapy is medically necessary for the specific diagnosis

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Step Therapy

Verify the patient has tried less expensive alternatives first

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Cost Management

High-cost specialty drugs require additional oversight before approval

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Utilization Management

Ensure the right drug, right dose, right setting, right patient