What to Anticipate During 2020 Prior Authorization “Season”

2020 Formulary Changes Expected to Increase Number of Prior Authorization Requests

December 19, 2019  |  Dan Kelly, Clinical Pharmacist

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Today’s providers, especially those with smaller staff, are weighed down by seemingly endless paperwork and time-consuming administrative tasks that limit time spent with patients. This administrative burden can delay patient treatment, cause provider stress and lead to physician burnout.

What’s to blame for the disparate time spent outside of the examination room? One culprit is the traditional paper-based prior authorization (PA) process. In fact, approximately 66 percent of prescriptions rejected at the pharmacy require PA, and of those, 36 percent are abandoned.1 We have also historically seen a 55 percent increase in the number of PA requests at the beginning of the year as a result of changes in prescription coverage, formulary modifications and renewal requirements.

What’s worse is that most providers don’t know when a prescription requires a PA until the pharmacy notifies them.2 This often results in a delay for the patient, as time to therapy is prolonged because of time spent on faxes, phone calls and reactive paperwork.

An electronic prior authorization (ePA) solution like CoverMyMeds can alert providers to medications that have new PA requirements as a result of formulary changes. This helps eliminate paperwork, ensuring PA requests are submitted securely and produces faster determinations.

To help avoid confusion over what changes were made from the previous year, review the following important formulary updates.

2020 Formulary Updates

Express Scripts National Preferred Formulary (NPF)
Adding: Abbott Freestyle and Precision diabetes testing supplies (diabetes), Nivestym (granulocyte colony stimulating factor)
Removing: Aubagio (multiple sclerosis), Granix (granulocyte colony stimulating factor), Nuwiq (factor VII recombinant products), Akynzeo (antiemetics), Emend powder packets (antiemetics), Pennsaid (topical NSAIDs), Striverdi Respimat (long-acting beta agonist inhalers)
View the formulary »

CVS Caremark Commercial
Adding: Tremfya (autoimmune agents), Yonsa (antiandrogens)
Removing: Combivent Respimat (anticholinergic / beta agonist combinations), Asmanex (steroid inhalants)
View the formulary »

United Healthcare Commercial
Adding: Retacrit (anemia), Yupelri (COPD), Rinvoq (inflammatory conditions), Skyrizi (inflammatory conditions), Inbrija (Parkinson’s disease)
Removing: Tudorza Pressair (COPD), Lonhala Magnair (COPD), ZTLido (neuropathic pain), Epogen (anemia), Procrit (anemia), Xyosted (testosterone replacement), Ilumya (inflammatory conditions), Taltz (inflammatory conditions)
View the formulary »

Cigna Commercial Standard Prescription Drug List
Adding: Vascepa (cholesterol medications), Steglatro, Segluromet (diabetes), Gonal-F, Gonal-F RFF (infertility)
Removing: Spiriva HandiHaler, Spiriva Respimat, Stiolto Respimat, Striverdi Respimat (asthma/COPD/respiratory), alogliptin, alogliptin-metformin (diabetes), Aubagio (multiple sclerosis), Follistim AQ (infertility)
View the formulary »

Humana Medicare
Removing: Tudorza Pressair (COPD)
View the formulary »

Join the more than 700,000 providers already using the CoverMyMeds solution by signing up here. Call 866-452-5017 to reach our dedicated support team for help.


[1] 2019 ePA National Adoption Scorecard
[2] CoverMyMeds Provider Survey, 2018

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