Depending on who you ask, prior authorizations (PAs) are either an efficient way to control medication costs or yet another administrative burden that take up valuable caregiver time, and too often stand in the way of a patient receiving a prescribed medication or service.

Pharmacy benefit manager (PBM) OptumRx emphasizes the role PAs have in helping to “manage costs, control misuse and protect patient safety,” while CVS Caremark cites their importance in minimizing the risk of an adverse reaction and identifying possible therapeutic alternatives.

Physicians seem to have a less favorable attitude about PAs, which the American Medical Association (AMA) defines as “a cost-control process that requires health care professionals to obtain advance approval from health plans before a prescription medication or medical service qualifies for payment and can be delivered to the patient.”  A statement from the AMA notes: “…physicians and other providers find these programs to be time-consuming barriers to the delivery of necessary treatment.”

Another interested party, of course, is the nation’s pharmacists.  This includes the thousands of individuals on the frontlines who interact directly with patients and navigate the rules each payer sets for its PA process.  For their part, pharmacists seem most interested in improving PA processes to add uniformity and eliminate administrative roadblocks.   “Currently each plan and PBM has different requirements for prescribers and pharmacists when a medication requires prior authorization,” the American Pharmacists Association (APhA) wrote in a 2021 letter to federal regulators.   “All these additional steps delay patients’ access to their medically necessary services or prescribed medications and detract from the practitioner’s capacity to provide care directly to the patient.”

Love, hate, or tolerate them, prior authorizations are an unavoidable part of U.S. healthcare practices, and positioned to become even more of a factor as high-cost specialty medications become more widely prescribed.

One area of agreement though, is the need to improve the process for submitting and tracking prior authorization requests.  CoverMyMeds, now a division of McKesson, has addressed this need with a technology-based solution that automates the PA process for prescribers, pharmacists, and payers.  The CoverMyMeds solution has dramatically reduced administrative burdens and processing times and helped facilitate patient access to their medications.

Today the CoverMyMeds electronic prior authorization (ePA) solution is the industry standard, with participation rates that include more than 50,000 pharmacies, 900,000 providers and payers representing almost 95% of total prescription volume.  CoverMyMeds is available to the healthcare community at no cost, and developers have gone out of their way to make the solution as accessible as possible.  PrimeRx users, for example, can integrate directly with CoverMyMeds, and access its functionality from within PrimeRx.

Despite this widespread and easy access, nearly half of all prior authorizations are still submitted via traditional channels including phone and fax.  Better communication about the benefits of electronic filing, along with improved insight into plan and payer PA requirements will be essential to improving ePA adoption.

In the meantime, the solution has been especially helpful for pharmacies.   That’s because, as analysis by CoverMyMeds points out, “when it comes to the PA process, most of the time and energy burden is on pharmacists.”  Research by the AMA, for example, found that 60% of physicians don’t even begin the PA process until they are notified – usually by a pharmacy – that a PA is required. One reason for this, the research determined, is difficulty determining if a prescription requires prior authorization.  Nearly 64% of physicians said it was either “extremely difficult” or “somewhat difficult” to understand plan prescription drug PA requirements.  Only 11% found it easy to understand plan requirements.

CoverMyMeds ePA functionality has transformed the prior authorization process, especially for pharmacies.  Processes that previously required painstaking staff attention are now automated, and payer decisions can now be rendered in minutes, rather than days.  The solution has generated achievements that include:

  • Improved access to medications: Patients access their medications an average of 13.2 days sooner when PA requests are submitted prospectively (at the point of prescribing), rather than retrospectively (following a claim rejection).  Retrospective filings typically take place at the pharmacy.
    • However, as noted, most PAs are generated retrospectively. A survey of providers revealed that prior authorizations are initiated at the point of prescribing just 17% of the time.
  • Faster turnaround times: 62% of PA requests submitted electronically receive a determination within two hours.
  • Improved processing for specialty medications: ePA authorization for specialty medications reduces time-to-therapy on average, from 17 days to as few as 1.5 days.
  • Reduced administrative burdens. According to InsidePatientCare, manual prior authorizations take an average of 15 minutes to complete, while an electronic PA requires just 1-to-3 minutes.  Once a payer decision is received, it can be quickly transmitted to providers, eliminating the need for time-consuming telephone calls.
  • NCPDP and HIPAA Compliant. CoverMyMeds ePA functionality is compliant with HIPAA and state mandates for electronic requests.  The solution also meets the NCPDP Script Standard for ePA transactions.
  • Improved dispense rate: According to Healthcare Innovation, ePA solutions can “lead to an 80 percent higher dispense rate and three percent greater likelihood that patients pickup their medications.”  This is due to the accelerated rate at which prescriptions are filled via an electronic PA, versus a PA submitted manually via fax or phone.

Prior authorization requirements have undoubtedly been a pain point for pharmacists, providers, and patients.  Automating the process though, has been a significant step forward, although many providers have yet to adopt electronic filing in their practices.  Much remains to be done though, to make the process more uniform, user-friendly, and predictable.

Significant efforts are underway, both at the state and federal levels to reform the prior authorization process.  Most notably, in January 2024 the Biden Administration announced a new regulatory rule that sets processing targets and makes other changes for prior authorization requests submitted on behalf of patients enrolled in government-backed insurance plans.  A glaring exception though, is that the rule does not apply to prescription drugs.

Instead, pharmacists can continue to find relief –and efficiency – by ensuring their technology system integrates with the CoverMyMeds electronic prior authorization solution.  With the number of medications requiring prior authorizations expected to increase, electronic PAs will become an even greater lifeline for today’s busy pharmacies.