Beers Criteria prior authorization for older adults
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This policy requires prior authorization (PA) for medications listed on the American Geriatrics Society Beers Criteria when prescribed to members aged 65 years and older to promote medication safety and reduce use of potentially harmful drugs.
No material clinical or coverage changes in this revision.
Coverage Criteria
Prior Authorization Criteria
Covered only with prior authorization when ALL of the following are met:
Prescribers should consider safer alternatives to promote medication safety in older adults
The table in this document provides a partial list of medications identified on the American Geriatrics Society Beers Criteria that will require prior authorization when prescribed to members aged 65 years and older. This list is not comprehensive; the policy refers readers to the full external lists and current formularies for complete information and updates. For the most current formularies and the full list of drugs to avoid, providers should consult the external resources referenced by the payer.
This policy does not use language declaring medications "not medically necessary." Instead, it establishes a requirement for prior authorization (PA) for medications listed on the AGS Beers Criteria when prescribed to members aged 65 years and older. Prescribers are encouraged to consider safer alternatives and to follow the PA submission instructions provided by the payer when a Beers-listed drug is contemplated.
Provider Actions & Submission Instructions
Prior authorization required for AGS Beers Criteria drugs (age ≥65)
Prior authorization is required for medications identified on the American Geriatrics Society (AGS) Beers Criteria when prescribed to members aged 65 years and older. Submit a PA before dispensing to avoid coverage denial.
- Requirement applies to members age 65 and older
- PA is intended to reduce prescribing of potentially harmful medications
Advise prescribers to use safer alternatives for older adults
Prescribers are advised to choose safer alternatives when possible to promote medication safety in older adults; the policy explicitly asks clinicians to “please prescribe safer alternatives for our members.”
- Consider alternatives due to age-related changes (renal function, CNS sensitivity, fall risk, drug accumulation)
- The policy’s goal is to promote medication safety and appropriate use
How to submit prior authorization requests
Submit prior authorization requests electronically via PromptPA, Surescripts, or CoverMyMeds, or fax the completed pharmacy form (available on the AlohaCare provider forms page) to 1-866-728-0233 (QUEST Integration). For questions contact the AlohaCare Pharmacy Department at PharmacyTechnicians@alohacare.org or ClinicalPharmacists@alohacare.org.
- PromptPA: https://alohacare.promptpa.com
- Surescripts: http://providerportal.surescripts.net/providerportal
- CoverMyMeds: https://www.covermymeds.com/main/prior-authorization-forms/
- Fax: 1-866-728-0233 (QUEST Integration)
Lack of prior authorization may result in denial
Prescriptions for medications on the AGS Beers Criteria for members aged 65 and older will require prior authorization; absence of an approved PA may result in denial of coverage and inability to dispense the medication through the plan.
- PA must be obtained prior to coverage for Beers-listed drugs in members ≥65
- Lack of PA may result in denial of coverage
Background
Medications included in the AGS Beers Criteria carry higher risk for older adults due to age-related physiologic changes. Factors such as altered renal function, increased central nervous system sensitivity, greater risk of falls, and potential for drug accumulation increase the likelihood of adverse effects in this population. The policy’s PA requirement for members aged 65 years and older is intended to promote medication safety by prompting review of Beers-listed prescriptions and encouraging safer therapeutic choices.
Definitions
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