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Turn phone calls and faxes into real-time PA determinations.

Our industry-leading PA volume allows most plans to automate 20-40% of PA requests on their first day of CoverMyMeds integration.

Reduce Administrative Waste

CoverMyMeds’ software enables providers to complete requests online, eliminating phone calls and faxes to plans.

Faster Determinations

Auto-determination functionality enables CoverMyMeds to provide determination recommendations to staff based on plan-specific criteria.

Validated, Accurate PA requests

Required and recommended fields direct providers to complete PA requests with all the necessary information, cutting down on requests for more information.


Resources

Learn more about the successes and innovations of CoverMyMeds technology.

CASE STUDY: Prior Authorization Renewals—CoverMyMeds Improves Continuity of Care for Patients Read More »

CASE STUDY: Regional Health Plan Increases Provider Adoption, Reduces PA Burden with CoverMyMeds Read More »

BLOG: Electronic Prior Authorization Legislation Signed by New York Governor Read More »

BLOG: Electronic Prescribing and Prior Authorization—Key Differences You Need to Understand Read More »

PRESS RELEASE: CoverMyMeds Selected as Electronic Prior Authorization Partner by EnvisionRx Read More »



PBMs/ Plan Who Work With CoverMyMeds

CoverMyMeds has relationships with payers that represent 75 percent of U.S. prescription volume, and our software is capable of working with all plans.

Prime Therapeutics cvscaremark 

aetnaMayo Clinic Health Solutions

Catamaran

See all partners »



Top FAQs for payers

Payers will ultimately need to support the NCPDP ePA standard. This four-part XML transaction is similar to E-Prescribing, and was recommended by NCVHS for adoption as the named HIPAA-standard for pharmacy prior authorization.

Some payers have built their own technology to exchange these NCPDP ePA transactions, and others have asked their PA workflow software vendor to do the work. CoverMyMeds is happy to integrate using either of these approaches and has completed integrations with most popular PA and BPM software vendors.

A third option is to run CoverMyMeds’ stack of cloud-based technology. This technology is available on a software-as-a-service (SaaS) basis and includes:

Criteria Builder, software for clinical staff to manage their PA criteria so that it can be used to generate NCPDP-compliant ePA transactions in addition to the more typical printed “PA forms” output. This criterion includes the ability to provide auto-determination so that real-time approval can be granted in the E-Prescribing workflow.

Central, a workflow management tool that comes pre-integrated for ePA transactions. Payers can simply access their PA requests and manage their workflow through this flexible tool that is often a great fit for payers stuck on technology that is hard to integrate or doesn’t support specialty pharmacy very well.

You shouldn’t choose us *instead* of another vendor, but we should likely be your first partner.

We do not believe payers should form exclusive relationships with any ePA company (and despite some vendor’s claims, are not aware of any payers that actually have done so). Exclusives will result in incomplete market coverage, higher pricing and lack of competitive forces to improve the product.

While CoverMyMeds is today the only material source of ePA transactions, we expect that over time an ecosystem will develop, and it will be in most payer’s best interest to have several trading partners.

CoverMyMeds has been nearly every payer’s first integration partner because of our expertise making the process work, and because of our existing volume.

Because of our existing user base, on day one we are typically able to turn ~20 percent of each payer’s existing PA volume into electronic transactions. We have been through the process many times, are very easy to work with and can help payers develop something that will be a big success.

PA vendors that are pursuing exclusives are effectively saying that they can’t compete on their ePA product’s actual merits.

Despite vendor claims, we are not aware of a single payer that is exclusive to any one ePA company so far.

Moreover, this strategy is unlikely to be successful since it isn’t good for the customer. It is absolutely crazy for payers to do exclusives, and will lead to higher pricing, incomplete market coverage and poor performance. Any payer that makes the mistake of doing an exclusive is setting themselves to competitive disadvantage relative to everyone else who will be able to drive lower costs and better utilization.


Fixing PA is an opportunity to reduce a big source of administrative waste and suboptimal health outcomes:

  • PA is responsible for prescription abandonment rates between 40 and 70% (Hansen et al, JMCP, September 2009; Belazi, AJMC, June, 2013).
  • An average of 8 hours-per-week is spent per-physician dealing with PA requests (Health Affairs, Vol. 28 No 4, August 2009).
  • 91 percent of physicians say that “PAs are frustrating” (National Council for Prescription Drug Programs (NCPDP) ePA Task Group, 2011).

To confirm that PA is a big deal for your providers, CoverMyMeds can conduct an “overlap analysis” with our users to let you know how many transactions will be automated through the new ePA interface on day one.


That depends entirely upon your organization, but two to six months is typical.

We are happy to connect using the NCPDP ePA standard sent over a secure public internet or a VPN, but the fastest way to connect is to use our full stack of ePA software running in the cloud. This allows you to manage criteria, set up auto-determination and handle workflow without writing any custom code. A hybrid strategy is to use our Criteria Builder product to manage your PA criteria for standards-compliant ePA transactions with us and other trading partners but to use your existing workflow management tool using a simple integration where CoverMyMeds targets an existing import format you already use.


Auto-determination allows the payer to provide real-time approvals to the provider right inside the ePA workflow (including as part of the E-prescribing process). What does or does not get auto-approved is entirely up the payer.

So far, we are seeing real-time approvals approximately 30 percent of the time; however, this rate is increasing rapidly and should eventually approach the overall approval rate for all PAs (60-90%).


We integrate electronically with plans that represent about 75 percent of U.S. prescription volume and support the rest through our Universal Last Mile service. This service allows us to connect to any plan using their drug-specific paper PA forms while maintaining an electronic experience for the provider and pharmacy.


Providers use CoverMyMeds to manage their PA process for all plans. When CoverMyMeds cannot connect to the payer electronically, we use the data accumulated through the electronic process with the provider to send a fax on the payer’s drug-specific PA form.

This fax can easily be replaced by doing an ePA integration with CoverMyMeds. If you do not wish to do an ePA integration, CoverMyMeds will gladly coordinate updates to your paper forms so that we always have the latest available. This service is free to payers.


Yes, CoverMyMeds provides both end-user applications for providers as well as APIs for other clinical systems. All transactions, whether through our own software or integrated partners will end up going through your ePA integration.

Nearly all pharmacy dispensing systems on the market are already integrated with CoverMyMeds, and we are rapidly becoming the default provider for EHR and E-
prescribing vendors.

CoverMyMeds’ financial model includes significant incentives for these participants, and payers benefit from the integrations as part of their relationship with CoverMyMeds.

Prime Therapeutics, Humana, Caremark, Aetna, US Script a number of BCBS plans, and many more coming soon. You can see our full ePA payer list.


Pharmaceutical manufacturers are interested in ensuring patient access for their medications. These organizations work with CoverMyMeds to reduce the chance that a prescription is abandoned after a claim rejection in the pharmacy, and to educate doctors and their staff about the opportunity to make their PA process more efficient.

Importantly, CoverMyMeds makes its service available for all drugs (not just those of sponsoring manufacturers), does not influence the prescribing decision of the provider, and does not share any Protected Health Information (PHI) with the manufacturer.

Much like the way we work with payers, the involvement of pharmaceutical manufacturers helps make it possible for CoverMyMeds to offer our service for free to pharmacies, physicians and their staff, and to pay transaction fees to vendor participants.