Utilization management is a set of techniques used by payers on behalf of purchasers of healthcare benefits to manage healthcare costs, ensure services align with payers’ medical necessity criteria, and reduce or eliminate care that is wasteful, inefficient, or unnecessary. 

The two most common forms of utilization management are prior authorization and fail-first policies. They can be used (1) to direct prescribers to less expensive branded or generic medications, (2) to help ensure adherence to standards of care, (3) to identify dangerous medication interactions that prescribers may miss, particularly in cases where patients are receiving medications from multiple providers, and (4) control costs. 

Utilization Management for Medications for Addiction Treatment Toolkit

ASAM has developed a toolkit to educate clinicians on how to navigate the various forms of utilization management that payers apply to medications for addiction treatment. The toolkit provides background information on the utilization management process, as well as analysis of the advantages and disadvantages of various prior authorization methods. Funding for this initiative was made possible (in part) by grant no. 1H79TI081968 from SAMHSA through PCSS.

Report a Payer Issue to ASAM

Use this form to report issues with payers related to utilization management, parity or other areas.

AMA Prior Authorization Toolkit 

These resources from the AMA include tips to make the prior authorization process easier for physicians and staff.

ASAM Approved Prior Authorization Form for Buprenorphine

This form can be used when advocating with insurers about prior authorization process for buprenorphine.