Reducing Burden of Prior Authorizations in Dermatology

Automated dermatology medication substitutions generated by algorithms may address delays in the PA system.

Researchers have identified appropriate dermatology medication substitutions for specific classes of topical therapies that pharmacists can implement  — without delay — when the medications are not covered by Medicaid, according to study findings published in the Journal of the American Academy of Dermatology.

Medicaid patients may have delays in receiving or never receive prescribed dermatology medications owing to delays in the prior authorizations (PA) process as well as frequent changes in Medicaid formularies. Restrictions on medication formularies are negatively associated with adherence outcomes, and providers may be unaware of medications covered by Medicaid or the least expensive options for patients, researchers noted.

To address these issues, investigators developed an automated pharmacy substitution program for dermatology medications that are not covered by Medicaid and to ensure their timely receipt. The researchers created substitution algorithms for common topical medication classes with use of the 2022 Pennsylvania Statewide Preferred Drug List.

The high-potency topical corticosteroids substitution algorithm can be used to identify a medication without contacting the prescribing provider or engaging in the PA process if the medication is not covered by Medicaid. The algorithm for topical retinoids is organized according to strength and then vehicle type, as the strength of the retinoid was regarded as a more important factor for creating the substitutions. The medication substitution algorithms were assessed and approved by dermatologists.

In principle, our model should reduce the overall number of PAs submitted, delays in starting treatment, and the number of communications to prescribing providers.

Specific substitution recommendations in the algorithm for topical corticosteroids with very high potency include the use of clobetasol 0.05% cream as a preferred agent for nonpreferred agents such as various creams, ointments, lotions, foams, and sprays.

Preferred agents in the algorithm for topical retinoids include Differin (adapalene 0.1% cream; Galderma), Retin-A gel (0.01% and 0.025% tretinoin gel; Bausch Health), and Retin-A cream (0.025% tretinoin cream; Bausch Health).

“In principle, our model should reduce the overall number of PAs submitted, delays in starting treatment, and the number of communications to prescribing providers,” stated the investigators. “Future studies will measure the impact of the substitution algorithm on PAs within the department. Overall, streamlining the Medicaid PA process through a similar automated substitution program may reduce delays in treatment initiation and alleviate the administrative burden of PA.”

Disclosure: Several of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Omar D, Brown-Korsah JB, Taylor SC, Mollanazar N. Automated pharmacy substitution for medications not covered by Medicaid: a model for reducing the burden of prior authorizations in dermatology. J Am Acad Dermatol. Published online September 29, 2022. doi:10.1016/j.jaad.2022.09.039