Aligning on a Mission to Help Patients: A Chat with Express Scripts

January 30, 2018  |  Jessica Behrendsen

As electronic prior authorization (ePA) becomes more prevalent, it’s important to take a step back and remember why the option to submit prior authorization (PA) in a way that works for all stakeholders, took off so quickly. We sat down with Express Scripts to get feedback on what about ePA works from a PBM perspective.

CoverMyMeds: Why is ePA important to a health plan/PBM?

Express Scripts: In the past few years, the industry has seen remarkable growth in physician adoption and utilization of ePrescribing and electronic health record (EHR) use. This is a critical step toward building a more connected health care system. One of the next logical steps is to streamline the prior authorization (PA) process as well. All stakeholders (physicians, health plans, pharmacy benefit managers, pharmacies) participating in the PA process can benefit from an ePA solution.

Prior authorization requests are an important part of how plans manage the ever-increasing costs of health care. They ensure people take the most cost-effective and clinically appropriate medication. Express Scripts saw an opportunity to alleviate the manual nature of PA requests, so we invested significant IT development resources and created key partnerships over the past three years. Physicians can now use secure web portals or their EHR, if ePA functionality is enabled, to submit PA requests for Express Scripts members.

CoverMyMeds is one of those key partnerships as they share the Express Scripts mission to put medicine within reach of patients. We know physicians submit PA requests to a variety of plans and PBMs, not just Express Scripts. CoverMyMeds lets physicians and office staff complete requests for all drugs and all payers, including Medicaid, Medicare Part D and specialty medications. They also have online chat support, which we’ve heard from office staff is a great added service.

CoverMyMeds: What are some common misconceptions in the industry?

Express Scripts: Not everyone understands that there are transaction-based standards for ePA. As an industry leader, Express Scripts worked with the National Council of Prescription Drug Plans (NCPDP) to develop the standards, which are included in the NCPDP SCRIPT standard governing ePrescribing. These standards preserve flexibility for PBMs, working on behalf of health plans, to collect varied clinical information for their individual PA processes. Each unique data set is presented in a standard format for the physician, resulting in ease of use no matter who is receiving the ePA.

CoverMyMeds: What is the benefit of auto-determination? How does it help the provider?

Express Scripts: Electronic prior authorization affords many benefits to providers and can help alleviate the additional hours of administrative time they or their office staff spend managing PA requests. In addition, providers will have:

  • Clear direction on clinical requirements to get medicine to their patients more quickly.
  • Capabilities to proactively request new PA requests and renew existing requests up to 60 days before they expire.
  • Secure and efficient PA administration all in one place.
  • Streamlined questions, asking only those needed for the request, unlike fax forms.
  • The ability to attach documentation if required.

Most times, PA decisions take only minutes. Complex PA decision times may vary based on the need for further review. All this saved time decreases patient frustration waiting on a prescription to be filled. Even though patients aren’t involved in the PA process, ePA makes it easier for patients to do the right thing when it comes to taking their prescribed medication and ultimately increases the likelihood of adherence.

CoverMyMeds: What moves has Express Scripts made to encourage ePA adoption and innovation?

Express Scripts: Express Scripts started investing in ePA functionality over three years ago and has reached out to physicians in a variety of ways to encourage adoption; however, many health care providers don’t know ePA is available, so it’s crucial to educate them on its benefits and tell them how to get started. In addition, EHRs that are not enabled for ePA need to build the IT functionality into their systems. We’ve worked with CoverMyMeds and our own Coverage Review Department call center to implement an ePA starter program, which creates a shell ePA case for the physician, who then completes the request within the CoverMyMeds web portal. Since this program began in July 2016, over 86,000 ePA cases have successfully been completed. By providing a stellar user experience within the CoverMyMeds portal, physicians and office staff are more likely to do additional ePA requests.

Ultimately, physicians want to spend more time with patients and less time on paperwork, and ePA can help make that desire a reality.

While you’re managing PA requests this busy season, keep in mind the fastest way to get a determination from a health plan is to use a streamlined electronic solution like CoverMyMeds that directly links to PBMs like Express Scripts, often returning a determination within minutes.

Questions? Give us a call at 1-866-452-5017 or click to chat at the bottom right corner of the screen.

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