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DVHA says prior-authorization requirements cut after review; pharmacy PAs dropped 43% from prior year
Summary
DVHA staff told the House Appropriations Committee that a four‑year review prompted removal of many prior authorization requirements for Medicaid services; total prior authorizations fell to about 17,000 in FY24, a roughly 43% decline from the prior year, agency witnesses said.
Department of Vermont Health Access officials told the House Appropriations Committee on Feb. 12 that the agency removed a number of prior authorization (PA) requirements after a multi-year review and a pandemic-era suspension showed no systemic misuse.
Sandy Hoffman, deputy commissioner of the Department of Vermont Health Access, said the agency reviewed four years of data and concluded many prior authorizations could be eliminated while retaining medical-necessity documentation requirements. “We removed the requirements for prior authorization before getting the service,” Hoffman said. The agency now relies on providers to document medical necessity and says it will audit or review cases if utilization anomalies appear.
Alicia Cooper, director of managed care operations, explained value-based payment models were part of the context for the shift, noting that some authorizations remain in place for medications that are not on the preferred drug list or that pose imminent harm to members. “Anything that’s not on the preferred drug list requires prior authorization. Anything that could be considered harmful to a member requires authorization,” Cooper said.
Supporting details presented to the committee: - Total prior authorizations in FY24: roughly 17,000, described by DVHA as about a 43% decrease from the prior year. - The agency said it suspended many PA requirements during the COVID-19 emergency and used the suspension period to analyze whether suspending PAs led to overuse or inappropriate care. Officials reported they found no evidence of widespread misuse during that period. - DVHA retains a limited “imminent harm” list and continues to require PA for non-preferred drugs and procedures that present safety risks. - The agency said it will monitor claims and clinical documentation and reintroduce review if utilization trends indicate anomalies.
Committee reaction and follow-up: lawmakers asked whether fewer PAs meant members were not receiving care; committee members and staff sought clarity on whether removing PAs affected access or outcomes. DVHA said it will continue data monitoring and perform targeted reviews if utilization spikes occur.
Ending: DVHA emphasized the change is intended to reduce administrative burden and speed access to care while maintaining safeguards for safety-sensitive drugs and treatments.
