Giving clinicians the ability to electronically request prior authorizations for certain medications will simplify a time-consuming, sometimes frustrating process.

Marianne Kolbasuk McGee, Senior Writer, InformationWeek

May 23, 2011

3 Min Read

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When a patient needs prior authorization from an insurer for a prescription, that can slow down the process of getting the medication filled. However, a new pilot under way by CVS Caremark aims to speed things up.

CVS Caremark is testing electronic prior authorizations that can be integrated into the workflow of writing e-prescriptions. The general popularity of e-prescribing is soaring as more clinicians adopt e-health record systems and other applications that facilitate electronic ordering of patient medications.

Under the pilot, the new real-time integrated electronic prior authorization, or ePA, capability will be available to CVS Caremark pharmacy benefit management clients. The ePA functionality helps simplify an often-time-consuming step required by payers and PBMs when doctors prescribe certain drugs for some patients.

In addition to CVS Caremark, a couple of other payers have signed on to participate in the ePA pilot, including Blue Cross Blue Shield of Tennessee and Horizon Blue Cross Blue Shield of New Jersey. Physicians and other providers throughout Tennessee and New Jersey who participate with either of those Blue Cross Blue Shield plans also have the ability to check real-time prior authorization status for their patients' medications.

The pilot aims to give doctors who place prescription orders for patients via e-prescribing or e-health record software an added workflow capability of also requesting prior authorization from CSV Caremark electronically, so the prescription can be filled more quickly.

Prescribers will also have an option to place ePAs via a client portal.

Typically, when a patient needs prior authorization for a prescription, the process involves phone calls, faxes, or hard-copy forms among doctors, patients, and pharmacies. This can delay patients from getting their medications, especially when prior authorizations are denied.

Under the pilot, prescribers can send an ePA request that details the coverage criteria related to a prior authorization. The prescribing clinician receives real-time status updates regarding approval of the medication.

CVS Caremark is working with several partners on its ePA pilot, including Surescripts, which operates the largest e-prescribing network in the United States.

Also participating in the pilot are NaviNet, through its NaviNet Mobile Connect platform, and Allscripts, whose client base includes former users of CVS Caremark's proprietary iScribe e-prescribing tool, which was transitioned to Allscripts ePrescribe software last year.

Additionally, MedPlus plans to include ePA functionality in a future release of its e-prescribing software, CVS Caremark said in a statement.

CVS Caremark is among the largest pharmacy benefits managers in the U.S., with a network of approximately 65,000 pharmacies, including more than 7,100 CVS pharmacy stores.

CVS Caremark said the pilot could help in the development of industry-wide standards for ePA transactions. CVS Caremark plans to share is ePA work with ANSI-accredited standards organizations to help drive the adoption of ePA standards by payers and healthcare provider organizations.

Technical guidelines for the pilot test have been published and are available through CVS Caremark.

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About the Author(s)

Marianne Kolbasuk McGee

Senior Writer, InformationWeek

Marianne Kolbasuk McGee is a former editor for InformationWeek.

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