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Drug Prior Authorizations Should Improve Medication Adherence
By Jocelyn Keegan

Pharmacies, pharmacy benefit managers (PBMs), and provider offices are challenged by how to streamline the drug prior authorization process to gather the most relevant clinical information.

There are many hurdles. For example, more than 90% of drug prior authorizations require a phone call or faxed request at an estimated cost to the plan of up to $75 for each authorization, and the number of instances for which a formulary drug requires prior authorization has doubled in the past six years. Furthermore, providers often use out-of-date questions, incorrect forms, and even submit requests to the wrong PBM.

Getting Prescriptions Into Patients’ Hands Faster
A provider wants to ensure that patients can get their prescribed drugs as quickly and easily as possible. Drug authorizations save providers time because a user can quickly obtain the correct form for a specific patient for a specific drug. For prior authorizations that make it to the pharmacy without the correct approval, a pharmacy can now create an electronic fax request for the provider to complete the clinical data required for a decision. Electronic prior authorizations (ePAs) will provide a near-real-time answer for the specific request vs. having to wait 48 to 72 hours for an answer, which is the case today.

The first goal is to get the provider the correct form as quickly as possible, so the information exchange can be focused on the most accurate clinical questions and patient information relative to the medicine needed with as little time and effort wasted for all parties. The secondary goal is to allow pharmacies, PBMs, and providers to create an electronic workflow that enables all of the parties to understand the status of a prior authorization at any time—to essentially create an on-ramp to ePAs.

In its ideal form, the ePA allows doctors to have a conversation directly with the patient about specific formulary options while the patient is in the office. Many doctors may understand the need for a prior authorization for a specific patient, but because of the way the system works now and their desire to get the authorization processed as quickly as possible, they often send the prescription through to the pharmacy to create the failed claim. A provider’s EHR, the pharmacy network tools, and the PBM’s rules engines are all disparate, closed solutions. Sharing critical information with a common tool would allow each of these participants to create prior authorization requests in a common way.

A Multipayer Solution Makes Sense
PBMs understand the value in participating in a multipayer solution because they have had their own struggles launching stand-alone ePA portals. While there is a lack of published data, NaviNet’s discussions with PBMs have found that provider utilization of these one-off solutions has been low. PBMs recognize the benefits of allowing providers to get to the right form quickly. They want to get fast, accurate answers to prior authorization requests, which can be easily determined by answering the correct questions and some branching logic. The move from the current phone- and fax-based system will be an evolution for the industry.

Today, an all-payer prior authorization solution allows both nonexpert and expert clinicians and staff to easily find and fill out the correct forms to expedite access to the medication, improving the likelihood of medication adherence. The arrival of near-real-time electronic adjudication with a PBM directly would further facilitate this process.

As e-prescribing tools—stand-alone and those imbedded in EHR platforms—improve to the point that they alert a provider about the need for a prior authorization when writing the prescription, the provider will be able to have a dialogue about a particular event and prescription options, eliminating some unnecessary prior authorizations (eg, quantity limits, step-therapy requirements, patient affordability issues) and allowing providers to proactively communicate with the PBMs to complete the authorization—and, even better, an ePA— before a patient arrives at the pharmacy. The improved process dramatically increases the likelihood of adherence—the ultimate quality goal.

NaviNet and CoverMyMeds are actively participating in ongoing ePA pilot with CVS Caremark using the National Council for Prescription Drug Programs candidate standards for adjudication. Providers will have near–real-time access to the specific question sets for a particular PBM for a specific patient’s pharmaceutical needs, leveraging a direct connection to a PBM’s rules engine, enabling the PBM to automate straightforward decisions, and focusing the PBM and provider on cases that require additional clinical background information to reach a decision.

— Jocelyn Keegan is the product manager for NaviNet Drug Authorizations and manages NaviNet’s partnerships with CoverMyMeds and CVS Caremark.