Electronic Prior Authorization

Despite the availability — and proven benefits — of an electronic solution, half of prior authorization volume still occurs through phone and fax channels. We explore what’s causing the lag in adoption, how optimization may impact the use of an electronic solution and the potential impact of adoption on patients’ access to the medications they need to live healthy lives. Read the full report below or download the executive summary.

ePA Report

Introduction

The benefits are widely known: When a prescription prior authorization (PA) is submitted electronically, patients get their medications faster and are more likely to adhere to their prescribed treatment.CoverMyMeds data on file, 2019

Because of this, electronic prior authorization (ePA) has been embraced across the healthcare network: Today, nearly 100 percent of pharmacies, payers and electronic health records (EHRs) have an ePA solution.

Yet, despite rapid integration of ePA over the last decade, nearly half of PA volume is still submitted through traditional channels like phone and fax.Payer data collected by CoverMyMeds, 2018

In this sixth installment of our Electronic Prior Authorization National Adoption Report, we expand our focus on provider* adoption of ePA — examining the implications for patients’ access to medication, as well as how optimization of ePA may lead to greater adoption.

Continued education of the benefits of ePA may encourage provider adoption. The healthcare network should continue to update current processes to limit the use of outdated PA channels and to help achieve provider adoption across the board. Focus should shift, too, toward the benefits of prescription decision support (PDS) solutions that include ePA, making the prospective PA requests a more organic part of a prescriber’s workflow.

As health systems continue to grow at a rapid pace, ensuring an ePA solution is readily available will not only help reduce provider burden but may also benefit patient health. Data shows that the adoption of ePA through EHR systems and health systems correlates with a decrease in time to therapy and, overall, an increase in patient medication adherence.CoverMyMeds data on file, 2019

*We define “provider” as a prescriber and any member of their care team, inclusive of nurses, medical assistants, office managers and prior authorization specialists.

Status of ePA

Understanding factors that influence provider adoption of ePA is critical for industry-wide success of the solution, as more than half of all PA volume still occurs over the phone and by fax.

PA Workflows

Prior authorization requests can be started at the point of prescribing (prospective) or following claim rejection (retrospective), typically at the pharmacy.

A recent case study illustrated that patients access their medications an average of 13.2 days sooner when requests are submitted prospectively versus retrospectively.CoverMyMeds data on file, 2018 Nevertheless, retrospective ePA volume continues to outpace prospective ePA volume, suggesting providers may not be aware of the true time and cost savings available through prospective ePA.

In a recent survey of 400 providers, 60 percent of respondents reported that their practice completes PA requests retrospectively, after the pharmacy has notified them that PA is required. Twenty percent reported that they complete requests after a patient has notified them of a PA requirement, while just 17 percent reported that they start a PA at the point of prescribing.CoverMyMeds Provider Survey, 2019

One reason providers avoid starting PA requests at the point of prescribing? They don’t fully trust the plan formulary information supplied in their EHRs. Sixty percent reported they only sometimes trust the insurance data available in their EHR, while 19 percent reported they rarely or never trust this information.CoverMyMeds Provider Survey, 2019

Emerging real-time benefit check (RTBC) technology can supply providers with high-accuracy patient information at the point of prescribing, providing visibility into PA requirements for a prescription. Already, RTBC and ePA are utilized as a powerful combination to increase speed to therapy.

An RTBC solution may not persuade a provider to complete a PA request prospectively. In fact, with this data, a provider may decide to prescribe an alternative medication that doesn’t require PA or help their patient find a cash option. Yet, greater insight into options at the point of prescribing may result in more consistent, confident PA processes.

What's Inhibiting Total ePA Adoption?

Despite evidence that the use of an electronic solution results in faster PA determinations, 49 percent of providers reported occasionally using non-electronic methods (i.e., phone and fax) to complete PA requests for certain situations.

One-third of providers are still using phone and fax to complete PA requests.

Though 62 percent of PA requests submitted electronically receive a determination within two hours, and 43 percent receive a determination automatically,CoverMyMeds data on file, 2018 33 percent of providers still choose phone or fax over ePA to complete urgent requests.CoverMyMeds Provider Survey, 2019

Twenty-eight percent of providers surveyed said they revert to non-electronic methods when handling a complex prescription situation, 20 percent automatically use non-electronic methods when they’re unsure if ePA is an option for a specific plan and 19 percent choose manual submission for specialty medications.CoverMyMeds Provider Survey, 2019

The Evolution of ePA

Due to the overwhelming number of retrospective PA requests, it’s often the pharmacist who’s responsible for answering patients’ questions and initiating the PA.

While the industry’s long-term goal should be to empower providers to start PA requests prospectively with the help of an RTBC tool, a near-term solution is the use of an automatic pharmacy PA solution.

This technology automatically initiates a PA request when one is likely to be required based on historical data, notifying the provider of a rejection and resolution option and decreasing the likelihood that a prescription is abandoned.

Understanding Administrative Burden

Providers report spending significant time on administrative processes like PA. In addition to greater education on the benefits of ePA, optimization of the solution is critical for increasing provider adoption.

While intended to control costs, reduce unnecessary prescription drug use and optimize patient outcomes, PA can create a significant administrative burden for providers. In fact, 86 percent of physicians believe the burden of PA is high or extremely high, while 88 percent feel the burden of PA has increased in the last five years.American Medical Association Prior Authorization Survey, 2018

On average, providers spend 14.9 hours — approximately two business days — on their PA workload.American Medical Association Prior Authorization Survey, 2018

In a survey, 1,453 providers outlined the challenges plaguing the PA process and the benefits of ePA.CoverMyMeds Provider Survey, 2018 Despite these benefits, more than half of all PA volume still occurs through phone and fax channels.

This manual, time-consuming process has implications beyond the doctor’s office, affecting pharmacies, health plans and, ultimately, the patient.

Provider sentiment of PA versus ePA

Physician Burnout

According to the American Medical Association’s most recent survey on the topic, the provider burnout rate has, for the first time since 2011, dropped below 50 percent. In a survey of more than 5,000 physicians, 43.9 percent reported at least one symptom of burnout (emotional exhaustion, feelings of cynicism and detachment from work, and a sense of low personal accomplishment), compared with nearly 55 percent in 2014.Changes in Burnout and Satisfaction with Work-Life Integration in Physicians and the General U.S. Working Population Between 2011 and 2017, Mayo Clinic

Despite this positive shift, there are opportunities, especially within the PA process, to reduce burnout further.

Data highlighting the administrative burden of PA and related processes

Twenty-six percent of survey respondents reported that, as the result of administrative work like PA, they’ve seen a reduction in face-to-face time with patients. Sixteen percent reported that they have less time to interpret lab and scan results, and 16 percent reported they experience less staff interaction.CoverMyMeds Provider Survey, 2019

In another survey, 71 percent of nurses were less than satisfied with the amount of time they spend on the phone dealing with insurance issues, such as PA.CoverMyMeds Nurse Survey, 2019

Prospective submission via an existing PA workflow can help a provider get ahead of the additional work that often arises when a PA requirement isn’t realized until the claim is rejected at the pharmacy. Submitting PA requests at the point of prescribing often results in significantly faster completions, leaving providers more time to engage with the work they want to prioritize.

Increased provider adoption of ePA has positive implications for the rest of the network, too. When a provider submits a PA electronically, they’re notifying the health plan and pharmacy sooner. This communication and coordination among network partners leads to better outcomes for patients: A medication is more likely to be dispensed (i.e., picked up by a patient) if the turnaround time for the PA process is short. Using phone and fax for PA requests can delay medication dispense by a full day.CoverMyMeds data on file — Effect of ePA Turnaround Time on Dispense Rate, 2018

Greater optimization of an electronic solution may encourage providers to reject phone and fax channels in favor of ePA. We recommend providers couple ePA with an RTBC solution during the ePrescribing process and shift from retrospective to prospective PA submission, and that health plans and prescription benefit managers (PBMs) update and modernize existing technical infrastructure and processes related to PA.

Centralized PA: Streamlining the Process

Electronic prior authorization was developed with providers in mind, with a goal to reduce their administrative burden — and to enable patient- and drug-specific PA in real time.

And across health systems, a trend is emerging: Centralized teams of administrators dedicated to completing PA requests, a staffing shift that may positively impact provider burden — and reduce PA burnout.

According to a recent American Medical Association survey, 36 percent of physicians have staff who work exclusively on PA.American Medical Association Prior Authorization Survey, 2018

One-third of those surveyed reported they use a centralized approach for PA. They noted faster completion, consistent processes and lower administrative burdens as benefits.CoverMyMeds Provider Survey, 2019

ePA and Patient Impact

The use of ePA over traditional phone and fax channels has positive implications for patients’ access to medication, significantly reducing time to therapy.

Patient Impact

In a recent provider survey, 91 percent of respondents reported that PA results in delayed access to necessary care. In the same survey, 75 percent of respondents reported that the PA process has led to patients abandoning treatment altogether.American Medical Association Prior Authorization Survey, 2018

In a different survey of 1,000 people, 55 percent reported delays in time to therapy due to a prescribed medication requiring PA.CoverMyMeds Patient Survey, 2019

Prescription abandonment increases the risk of future health problems or hospitalization. The utilization of an electronic solution may increase patient medication adherence by helping to ensure patients leave the pharmacy with prescription in-hand.

When a patient perceives they have access to the medication prescribed for them by their provider, the probability that they’ll pick up their prescriptions and adhere to therapy increases.

Not only can accelerated turnaround times on ePA determinations affect dispense rates at the pharmacy, the improved patient perception of access to medications can translate to a three percent greater likelihood that patients will pick up their prescriptions from the pharmacy.CoverMyMeds data on file, 2018

Highlighting the impact of channel on medication dispense rate

ePA and Specialty Medication

For patients prescribed specialty medication, delays in time to therapy can be significant. Though prescribing these medications is far more complex for all involved, the use of ePA is still beneficial.

Due to an aging population, a growing number of Americans with complex and chronic diseases and a shift in drug manufacturing trends, specialty medications are the fastest-growing segment of U.S. drug spend.

While there is no specific definition for what constitutes a specialty medication, it is generally agreed they are high-cost brand-name or generic medications (average wholesale acquisition cost of more than $670) for patients suffering from complex or rare diseases.Drug Channels Institute, 2019

Specialty medication access

The inherent complexity of specialty medications — unique administration (nebulizer, injections, infusions) and the need for consistent patient monitoring — is compounded by time-intensive up-front processes. In addition to PA, these include enrollment documentation, benefit verification and risk evaluation and mitigation strategies (REMS).

In fact, in a recent survey of 1,000 people, 60 percent of those currently prescribed a specialty medication reported experiencing at least some level of difficulty in obtaining their first dose.CoverMyMeds Patient Survey, 2019

When asked to rate the difficulty for starting patients on complex medications, 81 percent of survey respondents reported that the process is at least slightly difficult. Despite working well for approximately half of all specialty claims (i.e., those covered under the pharmacy benefit), ePA is still not widely recognized by providers as a solution for specialty medications.

In the same survey, 19 percent of respondents reported that they’re inclined to use phone and fax over ePA for specialty medications.

The Impact on Access and Adherence

A patient’s journey for specialty medications involves safety and educational components, as well as reimbursement protocols, that can collectively delay time to therapy three to six weeks, for some therapeutic areas.ePrescribing (eRx) of Specialty Medications — Where We Are and Where We’re Going, Point-of-Care Partners

Electronic prior authorization for specialty medications can reduce time to therapy significantly, from 17 days to as few as 1.5 days.CoverMyMeds data on file

ePA Legislation

Continued advocacy of ePA at the federal and state levels highlights the industry’s commitment to modernizing healthcare and protecting patients.

Federal Developments

H.R. 6, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, was signed into law on October 24, 2018. H.R. 6 — SUPPORT for Patients and Communities Act

Within H.R. 6 is a provision (Section 6062) stipulating utilization of ePA for drugs covered under Medicare Part D by January 1, 2021. This law requires the Centers for Medicare and Medicaid Services (CMS) to install regulations mandating Medicare Part D plans to accept PA requests submitted electronically — and requires the Secretary of Health and Human Services to consult with standards development organizations, including NCPDP.

Additionally, beginning January 1, 2020, the Centers for Medicare & Medicaid Services will require that Part D ePrescribing be conducted using solely the NCPDP SCRIPT Standard Version 2017071.

The opportunity to adopt the NCPDP SCRIPT Standard to expedite prescription PA is an opportunity for the Secretary to ensure the Medicare Part D program is utilizing a prevalent standard used in other markets today. The standard named by the Secretary must be implemented.

Types of Legislation

Many states are also adopting legislation around PA and ePA, with laws ranging from use of a standardized form for submission to mandating the use of the NCPDP SCRIPT Standard for ePA.

ePA (NCPDP Standard)

Calls for the use of an electronic method for submitting medication PA in compliance with the NCPDP SCRIPT Standard.

map featuring states that have epa and ncpdp standards

ePA (No Standard)

Calls for the use of an electronic method for submitting medication PA, but names no standard.

map featuring states that have epa but no form standard

Standard Form & ePA

Calls for the use of a universal or standard form as well as the use of an electronic method for submitting medication PA.

map featuring states that have standard form and epa requirements

Standard Form

Calls for the use of a universal or standard form for medication PA approved by the state’s Department of Insurance.

map featuring states that have form standards but no epa requirement

Legislation by State

The increase in legislation around PA and ePA has become more prevalent at the state level. Mandates range from use of a standardized form for submission to mandating the use of the NCPDP SCRIPT Standard for ePA.

  • AK

    Alaska

    State Legislation:

    No state legislation is proposed at the time of publication.

    WY

    AL

  • AL

    Alabama

    State Legislation:

    No state legislation is proposed at the time of publication.

    AK

    AR

  • AR

    Arkansas

    State Legislation: SB318

    A healthcare insurer must utilize only a single standardized PA and non-medical review form for obtaining approval in written or electronic form for prescription drug benefits. The form must be accessible through multiple computer systems. The required form must not exceed two pages and must be designed to be submitted electronically from a prescribing provider to a healthcare insurer.

    AL

    AZ

  • AZ

    Arizona

    State Legislation: SB1001

    The healthcare insurer or its utilization review agent must allow providers to access the PA request form, but no universal form has been named or adopted. Beginning January 1, 2020, the health insurer or its utilization review agent must now accept PA requests electronically, but no standard has been named; and the health insurer or its utilization review agent must provide at least two forms of access to request PA.

    AR

    CA

  • CA

    California

    State Legislation: SB282

    The Department of Managed Healthcare and the Department of Insurance jointly created a standard PA form, publishing rules effective July 1, 2017. The rule required the use of the adopted standard form on or before January 1, 2018. To request PA, every prescribing provider must use the adopted standard PA form or an ePA process utilizing the NCPDP SCRIPT Standard for ePA transactions. Every health insurer should accept that form or NCPDP SCRIPT Standard for ePA transactions as sufficient to request PA for prescription drugs.

    AZ

    CO

  • CO

    Colorado

    State Legislation: SB277; 3CCR 702-4; 4-2-49

    All carriers must utilize the uniform PA process established by the regulation. Though not required, a PA process for a drug benefit must allow for electronic submission. The carrier must make available on their website the standard form for PA for a drug benefit.

    CA

    CT

  • CT

    Connecticut

    State Legislation:

    No state legislation is proposed at the time of publication.

    CO

    DE

  • DE

    Delaware

    State Legislation: HB381

    The health insurer must accept and respond to PA requests through secure electronic transmission using the NCPDP SCRIPT Standard for ePA transaction. Faxes, proprietary payer portals and electronic forms are not considered electronic transmissions.

    CT

    FL

  • FL

    Florida

    State Legislation: HB221

    A health insurer or a PBM on behalf of the insurer, which does not have an ePA process for its contracted providers, must use only the PA form approved by the Financial Services Commission.

    DE

    GA

  • GA

    Georgia

    State Legislation: SB416

    Electronic prior authorization requests must be accessible and submitted by providers to PBMs and health plans through secure electronic transmissions utilizing the current NCPDP SCRIPT Standard for ePA. The healthcare provider is not required by adopted code to participate in ePA in order to obtain the necessary authorization for patient care; however, faxes are not considered an electronic submission except in the event that such ePA is temporarily unavailable due to system failure or outage.

    FL

    HI

  • HI

    Hawaii

    State Legislation:

    No state legislation is proposed at the time of publication.

    GA

    IA

  • IA

    Iowa

    State Legislation: ARC 2348C; HF766, section 63

    ARC 2348C: Each insurer is required to create a PA form unique to that insurer, not to exceed two pages and to be approved by the Commissioner of Insurance. The form must be made available electronically by the carrier or PBM. The form to be submitted by the health carrier must take into consideration forms developed by the Centers for Medicare and Medicaid Services or the U.S. Department of Health and Human Services and any national standards to include the NCPDP SCRIPT Standard. The division recognized the importance of technology to the industry and modified the proposed rule to emphasize that the statutory language requiring a form does not preclude the use of or compliance with NCPDP SCRIPT Standards.

    Iowa HF766, section 63: Uniform Medicaid Prior Authorization: The Department of Human Services must adopt administrative rules requiring that both managed care and fee-for-service payment and delivery systems utilize a uniform process, including but not limited to uniform forms, information requirements and time frames, to request medical PA under the Medicaid program, no later than October 1, 2019.

    HI

    ID

  • ID

    Idaho

    State Legislation:

    No state legislation is proposed at the time of publication.

    IA

    IL

  • IL

    Illinois

    State Legislation: HB2160

    The Department of Insurance and the Department of Healthcare and Family Services must develop a uniform ePA form to be used by an insurer or managed care organization that provides prescription drug benefits when requiring PA. The development of the uniform ePA form must include input from interested parties and the Department of Insurance and the Department of Healthcare and Family Services must take into consideration certain existing PA forms and national standards pertaining to ePA.

    Proposed State Legislation: HB2326

    On or before July 1, 2020, The Department of Insurance and Department of Healthcare and Family Services must jointly develop a uniform PA form to be used by prescribing providers to request PA for prescription drug benefits. On and after January 1, 2021, or 6 months after the uniform PA form is developed, whichever is later, health insurers, managed care organizations and fee-for-service medical assistance programs that provide prescription drug benefits shall utilize and accept the uniform PA form and prescribing providers may use the uniform PA form.

    ID

    IN

  • IN

    Indiana

    State Legislation: SB73; HB1546

    SB73: Effective Jan. 1, 2018, the bill requires a health plan to accept and respond to a PA from a prescriber or a pharmacist through an electronic transmission using the NCPDP SCRIPT Standard. Encourages all entities to use a common form for PA but no standard form created or mandated.

    HB1546: The measure requires, after December 31, 2020, that a Medicaid managed care organization use a standardized PA form prescribed by the Office of the Secretary of Family and Social Services. The measure also requires the electronic transmission of PA requests and determinations and allows only for exceptions to that requirement for specified reasons that are agreed to in advance of a request for PA.

    IL

    KS

  • KS

    Kansas

    State Legislation:

    No state legislation is proposed at the time of publication.

    IN

    KY

  • KY

    Kentucky

    State Legislation: SB144; KRS 217.211; SB54

    NCPDP adopted ePA standards in 2013. Within 24 months of NCPDP developing and making available national standards for ePA, each governmental unit of the Commonwealth communicating administrative regulations relating to ePrescribing must consider ePrescribing and ePA standards in its implementation of health information technology improvements as required by the Medicare Prescription Drug, Improvement and Modernization Act of 2003 and the Health Information Technology for Economic and Clinical Health Act, enacted as part of the American Recovery and Reinvestment Act of 2009.

    SB54 (passed March 26, 2019) requires that a process for electronically transmitting PA requests for drugs by providers must be developed by January 1, 2020. ePrescribing software displaying information regarding a payer's formulary, payments, or benefit plan must be updated at least quarterly. A health insurer must provide a utilization review decision concerning urgent healthcare services within 24 hours after obtaining all necessary information to make the utilization review. Utilization review decisions concerning non-urgent healthcare services must be provided within 72 hours of obtaining all necessary information. Does not apply to contracts providing Medicaid benefits.

    KS

    LA

  • LA

    Louisiana

    State Legislation: SB231; SB29

    SB231: Insurers are required to create their own standard PA form, no more than two pages in length and made it accessible through multiple computer operating systems. The forms must be filed with the Department of Insurance.

    SB29: The Louisiana Board of Pharmacy and the Louisiana State Board of Medical Examiners are required to create a single uniform prescription drug PA form and regulations prior to January 1, 2019.

    KY

    MA

  • MA

    Massachusetts

    State Legislation: Title XXII, Chapter 1760, Section 25

    Nothing should prohibit a payer or any entity acting for a payer under contract from using a PA methodology that utilizes an internet webpage, internet web portal or similar electronic, internet- and web-based system in lieu of a paper form, provided it is consistent with the paper form. A payer or any entity acting for a payer under contract, when requiring PA, must use and accept only the PA forms designated for the specific type of services and benefits.

    LA

    MD

  • MD

    Maryland

    State Legislation: HB1233

    Online, web-based process are required by payers and PBMs. Providers are required to use payer web portal OR standard transaction that has been established and adopted by the healthcare industry via EMR. Additional requirements regarding Step Therapy were also added.

    MA

    ME

  • ME

    Maine

    State Legislation: SP339; LD705

    SP339: Requires a health insurance carrier to accept and respond to PA requests through electronic transmission by January 1, 2019 for prescription drugs and medical services. The amendment also requires a carrier to make its most current prescription drug formulary available to health care professionals and pharmacists in electronic form at all times.

    LD705: Health insurance carriers must develop an electronic transmission system for PA of prescription drugs by January 1, 2020 and for medical services by July 1, 2020. Health insurance carriers must reduce the time frame for responding to a PA request from two business days to 48 hours for non-emergency services. Medication-assisted treatment for opioid disorder be excluded from PA requirements.

    MD

    MI

  • MI

    Michigan

    State Legislation: SB178

    If an insurer uses a PA methodology that utilizes an internet webpage, internet web portal or similar electronic, internet and web-based system, they will not be required to utilize the standard form adopted by the Department of Financial Services, Community Health or Insurance. The form approved by the Department of Insurance and Financial Services must be used in requesting PA for prescription drugs.

    ME

    MN

  • MN

    Minnesota

    State Legislation: 62J.497

    Drug PA requests must be accessible and submitted by healthcare providers, and accepted by group purchasers, electronically through secure electronic transmissions. Fax should not be considered an electronic transmission. The Minnesota Prescription Drug Companion Guide v1.1, names the NCPDP SCRIPT Standard for ePA transactions as the methodology for secure electronic transmissions. All healthcare providers must submit requests for formulary exceptions using the uniform form, and all payers must accept this form from healthcare providers.

    MI

    MO

  • MO

    Missouri

    State Legislation:

    No state legislation is proposed at the time of publication.

    MN

    MS

  • MS

    Mississippi

    State Legislation: HB301

    A health insurance issuer must use only a single, standardized PA form for obtaining any PA for prescription drug benefits. The form must also be made available electronically and the prescribing provider may submit the completed form electronically to the health benefit plan.

    MO

    MT

  • MT

    Montana

    State Legislation:

    No state legislation is proposed at the time of publication.

    MS

    NC

  • NC

    North Carolina

    State Legislation:

    No state legislation is proposed at the time of publication.

    MT

    ND

  • ND

    North Dakota

    State Legislation: HB1274

    Effective August 1, 2015, a drug PA request must be accessible to a healthcare provider with the provider's ePrescribing software system and must be accepted electronically, through a secure electronic transmission, by the payer, by the insurance company, or by the PBM responsible for implementing or adjudicating the authorization or denial of the PA request. For purposes of this section, a fax is not an electronic transmission.

    NC

    NE

  • NE

    Nebraska

    State Legislation:

    No state legislation is proposed at the time of publication.

    ND

    NH

  • NH

    New Hampshire

    State Legislation: HB1608

    Requires the Commissioner of Insurance to create a universal PA form to be accepted and used by insurers when requiring PA for medications or use of the NCPDP SCRIPT Standard for ePA. Electronic prior authorization is not required if a pharmacist or prescriber lacks broadband Internet; or has low patient volume; or has opted-out for a certain medical condition or for a patient request; or lacks an EMR system; or the ePA interface does not provide for the prepopulating of prescriber and patient information; or the ePA interface requires an additional cost to the prescriber. Does not apply to Medicaid. Rule INS 2705, passed March 8, 2017, Department of Insurance adopted PA universal form as required by HB1608.

    NE

    NJ

  • NJ

    New Jersey

    Proposed State Legislation: A.B. 2589

    Requires the Commissioner of Banking and Insurance to develop a standard PA form for use by network providers to determine coverage of prescription drug benefits. No effective date as of yet.

    NH

    NM

  • NM

    New Mexico

    State Legislation: SB296; SB188

    SB296: Requires a uniform PA form to be used by all plans. A health insurer must exchange PA requests with providers who have ePrescribing capability.

    SB188: Establishes PA requirements for medical care, pharmaceutical benefits or related benefits by every health insurer and provider. On or before September 1, 2019, the Office of the Superintendent of Insurance (OSI) must, in collaboration with health insurers and health providers, promulgate a uniform PA form for medical care, pharmaceutical benefits or related benefits to be used by every health insurer and provider after January 1, 2020. A health insurer that requires PA must use the uniform PA forms developed by OSI, establish an internal portal system for PA requests on a 24-hour, seven-days a week basis and auto adjudicate PA requests by January 1, 2021.

    NJ

    NV

  • NV

    Nevada

    State Legislation:

    No state legislation is proposed at the time of publication.

    NM

    NY

  • NY

    New York

    State Legislation: SB4721A

    Requires the Department of Health and Financial Services to develop standards for PA, taking into consideration the NCPDP SCRIPT Standard.

    NV

    OH

  • OH

    Ohio

    State Legislation: SB129

    Effective Jan. 1, 2018, insurers must permit healthcare providers to access the PA form through applicable electronic software. Insurers and PBMs must also accept PA requests through a secure electronic transmission using the NCPDP SCRIPT Standard. Faxes are not considered secure electronic transmissions and proprietary payer portals are not considered secure transactions unless they use the NCPDP SCRIPT standard. Prescribers and insurers can enter into contractual agreements foregoing this process if it’s an undue hardship.

    NY

    OK

  • OK

    Oklahoma

    State Legislation: HB2190

    A health benefit plan must utilize PA forms for obtaining any PA for prescription drug benefits. A form shall not exceed three pages. The form may be customizable to a specific drug. A health benefit plan may make the form accessible through multiple computer operating systems.

    OH

    OR

  • OR

    Oregon

    State Legislation: SB382; OAR 836-053-1205

    Plans must accept the requested universal PA form through any reasonable means of transmission, including but not limited to paper, electronic or another mutually agreeable accessible method of transmission or using an internet or web-based system.

    Proposed State Legislation: LC2049

    Health insurers must clearly post the criteria and process used in utilization review on their website, including all requirements for requesting PA, exceptions to step therapy protocols, specific documentation required for a request to be considered complete, and a list of the specific services, drugs or devices for which PA is required. Health insurers must have a website through which providers can make secure, electronic submissions of requests for PA. The insurer is also required to provide an electronic receipt to the provider.

    OK

    PA

  • PA

    Pennsylvania

    Proposed State Legislation: HB1293

    Prior authorization requests shall be accessible to healthcare practitioners and accepted by insurers, pharmacy benefits managers and utilization review organizations electronically through a secure electronic transmission using the NCPDP SCRIPT Standard ePA transactions. Fax, proprietary payer portals and electronic forms shall not be considered electronic transmissions. Act would take effect 60 days after passage of the law.

    OR

    RI

  • RI

    Rhode Island

    State Legislation:

    No state legislation is proposed at the time of publication.

    PA

    SC

  • SC

    South Carolina

    State Legislation:

    No state legislation is proposed at the time of publication.

    RI

    SD

  • SD

    South Dakota

    State Legislation:

    No state legislation is proposed at the time of publication.

    SC

    TN

  • TN

    Tennessee

    State Legislation:

    No state legislation is proposed at the time of publication.

    SD

    TX

  • TX

    Texas

    State Legislation: SB644

    Standard state adopted PA form required for PA requests. Mandate requires acceptance of NCPDP SCRIPT Standard of ePA.

    TN

    UT

  • UT

    Utah

    State Legislation:

    No state legislation is proposed at the time of publication.

    TX

    VA

  • VA

    Virginia

    State Legislation: HB1942

    HB1942: Requires carriers to accept phone, fax or electronic submission of PA requests that are delivered from E-Prescribing systems, EHRs and health information exchange platforms that utilize the NCPDP SCRIPT Standard. Requires all PA forms accepted by the carrier be made available through one central location on the carrier’s website and that information be updated by the carrier within seven days of approved changes.

    UT

    VT

  • VT

    Vermont

    State Legislation: HB559

    When requiring PA for prescription drugs, a health plan must accept for each PA request either the national standard transaction information or a uniform PA form. A health plan must have the capability to accept both the national standard transaction information and the uniform PA form.

    VA

    WA

  • WA

    Washington

    State Legislation: WAC Chapter 284-43-2020 (ii)

    Whenever there is an adverse determination resulting in a denial the issuer must notify the requesting provider by one or more of the following methods; phone, fax and/or secure electronic notification, and the covered person in writing or via secure electronic notification. Status information will be communicated to the billing pharmacy, via electronic transaction, upon the issuer’s receipt of a claim after the request has been denied.

    VT

    WI

  • WI

    Wisconsin

    State Legislation:

    No state legislation is proposed at the time of publication.

    WA

    WV

  • WV

    West Virginia

    State Legislation: SB2351

    Passed into law on March 1, 2019, health insurers must accept and respond to electronically submitted PA requests for pharmacy benefits by July 1, 2020. Health insurers must develop PA forms and portals and must accept one PA request for an episode of care. The forms must i. include instructions for the submission of clinical documentation; ii. provide an electronic notification confirming receipt of the PA request if forms are submitted electronically; iii. contain a comprehensive list of all procedures, services, drugs, devices, treatment, durable medical equipment and anything else for which the health insurer requires PA; iv. inform the patient if the health insurers require plan members to use step therapy protocols; and v. be prepared by October 1, 2019.

    Proposed State Legislation: SB2399

    The Governor must appoint a person who is knowledgeable in the creation of insurance forms to lead a collaborative effort of the Public Employees Insurance Agency, managed care organizations and private commercial insurers to develop universal PA forms accessible through either a computer program, email, app, or secure electronic transmission. The forms shall be prepared by October 1, 2019. The group may develop no more than eight forms differentiated by the type of service being requested.

    WI

    WY

  • WY

    Wyoming

    State Legislation:

    No state legislation is proposed at the time of publication.

    WV

    AK

Beyond the Standard Form

Though PA legislation has a positive impact on the industry, it’s important new legislation aligns with the most cutting-edge ePA technologies to make the most impact on streamlining PA.

While well-intentioned, laws requiring exclusive use of a standard form (despite pre-existing availability of ePA solutions) can inadvertently displace inefficiency, as the standard form cannot address all specific-use requirements that can arise during the PA process for various medications.

Looking ahead, it’s critical state legislators consider the availability of ePA solutions already active in their states and allow provisions for its use in standard form legislation to prevent unnecessary burden.

Conclusion

Completing PA requests through a manual process involving phone calls and faxes between pharmacies, providers and health plans is an inefficient, time-consuming process — and poses a significant medication access challenge for patients, one that often leads to prescription abandonment.

The adoption and optimization of an electronic solution — one that allows providers to complete prospective PA requests in their EHR or an ePA web portal — has the potential to not only simplify provider and pharmacist workloads, but also increase speed to therapy for millions of patients each day.

The Electronic Prior Authorization Report is written and published by CoverMyMeds with guidance from industry experts on the Advisory Board for the overarching Medication Access Report.