Pharmacy Benefit Managers Editing and Proofreading Services

A prescriber wants to put a patient on a drug that needs prior authorisation. They have nine minutes. Somewhere there is a criteria document setting out exactly what would be approved, and if they could see it in a usable form they would either meet it now or choose something else. Instead they submit, get declined, appeal, and eventually telephone — and every one of those steps was created by a document that described a policy instead of a checklist.

We edit what pharmacy benefit managers and formulary organisations produce — prior authorisation criteria and their prescriber-facing versions, formulary and tier documentation, step therapy requirements and exception routes, coverage determination letters and denial notices, appeal and exception process documentation, quantity limit and safety edit explanations, clinical policy documents and their evidence citations, provider manuals and portal guidance, member-facing benefit and coverage explanations, and pharmacy network and dispensing communications. Our editors work on the criteria document a prescriber uses under time pressure.

Prior authorisation criteria are where a formulary either functions or generates work for everybody, and their failure is being written as policy rather than as a form somebody completes. A document explaining the clinical rationale for a restriction is useful to a committee and useless at the desk. We work through these so the criteria are a numbered list of conditions with what evidence satisfies each, since a prescriber who can see that they need a documented trial of two agents for at least eight weeks each can check the notes in ninety seconds; so any requirement for prior treatment states what counts as a trial and what counts as a failure or intolerance, given that this is the commonest reason a submission is returned; so the exceptions are on the same page as the criteria — contraindication, intolerance, prior response — because a prescriber who cannot see the exception route submits a doomed request; so the required documentation is listed as documents rather than as concepts, naming the values, dates and notes that must be attached; so the decision timescale and the route for an urgent case are stated; and so the denial letter refers to the specific criterion not met and what would satisfy it, as a denial that quotes policy generates an appeal and one that names the missing item generates a resubmission. Criteria written this way reduce volume on both sides.

Everything you send is treated in confidence, including criteria, clinical policies and member communications. We are editors rather than clinical, pharmacy or benefits advisers, and we offer no view on coverage, criteria or determinations. What we can do is turn a policy into something completable at the desk.