Certain drugs on a formulary may require prior authorization (PA) before a patient can receive the medication. Drug Prior Authorization is a utilization management tool that requires the prescriber to provide clinical information (e.g. lab values, chart notes, etc.) in order for the payer to make a determination whether it will pay for the drug.
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The traditional prior authorization process relies heavily on fax and phone and involves prescribers, payers, pharmacists, and patients. The National Council on Prescription Drug Programs (NCPDP) noted several problems with the current state of drug prior authorization and the cumbersome flow of information1:
· “Prescribers often are not aware that a PA is needed until the prescription claim is rejected at the pharmacy. This leads to delays in 1) the opportunity to discuss the PA process with the patient 2) the potential to prescribe another medication, and 3) the patient’s treatment beginning as anticipated.“
· “Pharmacists are often playing middlemen, contacting the prescriber to initiate a PA, and notifying the patient of the coverage restriction. They spend time contacting the prescriber, either by phone, fax or via a secure transaction. They may also contact the payer to determine the status of the PA request and update the patient.”
· “Patients may learn of the need for a PA when they attempt to obtain their medication. They are then faced with the choice of waiting for the PA process to be completed, paying the full price for their prescription or not obtaining the medication.”
· “For payers the current manual process may result in delays as data received via phone or fax cannot be systematically reviewed. As more processes are handled electronically, reverting to paper, phone, or fax for communication between payers and prescribers may cause delays. “
With electronic Prior Authorization (ePA), the process is automated as the provider initiates the PA electronically at the point of prescribing within the EHR or electronic health record. According to the covermymeds scorecard, payers can expect to receive the most benefit from ePA solutions2:
- Time and cost savings due to the reduction in phone calls and faxes
- Decrease in time to therapy to improve member satisfaction and outcomes
- Increased medication adherence to limit unnecessary hospitalizations
- Complete and accurate initial submission of PA requests
- Possible real-time determinations based on preset, payer-specific criteria
