Electronic Prior Authorization can Increase Dispensing Workflow of Specialty Medications

Specialty Pharmacy TimesJuly/August 2016
Volume 7
Issue 4

Electronic prior authorization may enhance support for a value-based pharmaceutical market.

THE SPECIALTY DRUG MARKET is the fastest growing medication market, accounting for $124 billion in 2014.1

With many newly approved drugs being specialty medications, specialty pharmacies face an increased burden due to the complex workflow and patient management that accompany speciality drugs. In light of these challenges, it is important to investigate how technology can streamline processes for specialty pharmacies. Electronic prior authorization (ePA) is one such technology that has already become commonplace in pharmacies and providers’ offices nationwide.

Perhaps the best way to understand how ePA can improve specialty pharmacy is to examine what ePA has accomplished in the retail space and apply these findings to the speciality sector. Specialty pharmacy is in a unique position, as it has a higher amount of clinical information available to safely and effectively manage complex diseases and patients. The speciality industry must also continue to manage traditional pharmacy dispensing activities, such as prior authorization (PA), claims billing, and patient counseling.

State and national mandates can also complicate this for specialty pharmacies by disallowing pharmacy-direct submissions of PA even when the pharmacy is acting as the physician’s agent or has access to patient health records. Currently, these restrictions are largely seen in the Medicaid and Medicare space.2

The Prior Authorization Problem

Today, 71% of PA requests are initiated at the pharmacy as a result of a rejected claim.3 This requires pharmacists to spend an average of 5 hours per week dealing with a complex manual workflow via fax and phone. This process disrupts the completion of other paramount tasks and often results in the patient being sent home without medication in hand.

ePA in Retail Pharmacies

The integration of ePA into pharmacy systems has proven to reduce administrative waste, increase dispensing of prescribed medications, and achieve faster speed to therapy.4 In fact, 1 retail pharmacy chain experienced a 50% faster time to therapy after implementing an electronic solution in their retail locations. Recently, CoverMyMeds partnered with industry leaders, including the National Council for Prescription Drug Programs and the National Alliance of State Pharmacy Associations, to release an updated version of the ePA National Adoption Scorecard.

The scorecard was designed to outline the current state of ePA and quantify adoption rates of interested parties within the industry. This helps bring acknowledgment to the current state of ePA by highlighting areas of high adoption, as well as lagging sectors. Within the pharmacy sector, the percentage of pharmacies committed to ePA as of the third quarter of 2015 was 83%, a 13% increase from 2013.

Participating pharmacies, primarily retail locations, are now addressing the key issue of preventing PA disruption from creating a delay in, or cessation of, patient therapy, which can have detrimental downstream health effects and costs if action is not taken. Pharmacies have 2 options for ePA integration: inside their dispensing system, either third party or proprietary, or via a Web portal.

This flexibility allows pharmacies to implement the option best suited for their company. Pharmacies using an ePA solution have the ability to deliver an initated PA request to a prescriber via a Web portal or integrated electronic health records (EHRs) system. A list of notable pharmacies and pharmacy systems using ePA is available within the ePA National Adoption Scorecard at epascorecard.covermymeds.com. Most, but not all, pharmacies are committed.

One common objection from pharmacy business owners not using an ePA solution is, “How can we be certain the prescriber’s office will be able to work with us?”

The numbers regarding provider adoption are positive. In November 2014, an estimated 250,000 providers utilized an industry-leading electronic solution. Today, that number has grown to more than 500,000.2 Provider adoption will continue to increase in 2016 and beyond, with additional specialty drug approvals and PA volume.

Consequently, pharmacies who adopt ePA through their dispensing system, or via a Web portal, will experience significant connectivity with their prescribers. Additionally, EHR advancements and integrations are resulting in even more prescribers utilizing an ePA solution. Through EHR integrations, the possibility exists for PA requests to start at the point of prescribing, removing roadblocks to patient care.

At the time of the ePA scorecard publication, 70% of the EHR market was committed to implementing an ePA solution. Steadily increasing ePA volume through integrated EHR systems is proof 2016 will result in an even larger volume of electronic transactions. Electronic prior authorization vendors are acutely aware how the specialty drug trend includes opportunities and challenges for health care.

They understand there needs to be a way to increase access, decrease waste, and support a value-based pharmaceutical market. Electronic prior authorization is part of the solution. When speciality pharmacies adopt an ePA solution, they will experience decreased administrative time, faster speed to therapy for patients, and a healthier population as a result of receiving the medication they need.


  • Specialty Drugs, Medicaid Expansion Drive Jump in Prescription Spending," Modern Healthcare, April 2015
  • CMS. Chapter 18 of the Prescription Drug Benefit Manual — page 67. https://www.cms.gov/Medicare/Appeals-andGrievances/MedPrescriptDrugApplGriev/Downloads/Chapter18.zip. Accessed November 16, 2015
  • CoverMyMeds data. Epascorecard.covermymeds.com. Accessed November 16, 2015
  • CoverMyMeds data. Epascorecard.covermymeds.com. Accessed November 16, 2015

About the Author

JULIE HESSICK is the director, pharmacy benefit manager (PBM)/plan accounts at CoverMyMeds. She is responsible for account management and project management of all PBM and plan clients. She oversees development, launch, and ongoing implementations for ePA and CoverMyMeds Central solutions. With over 15 years working in PBM, specialty, mail order, and infusion services, Julie’s clinical experience helps CoverMyMeds build and maintain highly collaborative, long-term customer relationships. Before joining CoverMyMeds, Julie served as the manager of clinical services and manager of pharmacy operations, PBM, where she practiced clinical and administrative pharmacy in managed care, home infusion, and specialty settings. She is a registered pharmacist in 16 states.

Related Videos
Practice Pearl #1 Active Surveillance vs Treatment in Patients with NETs
© 2024 MJH Life Sciences

All rights reserved.