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05 ― Legislation

Prior authorization legislation has been in consideration—and in some cases in effect—since 2013. The intent of legislation is to make the PA submission process faster and easier for providers to prevent the delay of patient treatment.

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06 - EHR Availability

Federal Developments

In January 2018, H.R. 4841, the Standardizing Electronic Prior Authorization for Safe Prescribing Act, was introduced in the U.S. Congress. Additionally, Preventing Addiction for Susceptible Seniors (PASS) Act, H.R. 5773 was introduced, requiring Medicare drug plans to establish management programs for at-risk beneficiaries including the use of ePA for Part D.

This bipartisan bill is designed to move the needle on ePA usage in the Medicare Part D Program, improving prescription access for Medicare beneficiaries. It is a step forward to improving an outdated system and also improve efficiencies by standardizing the PA process.

Types of Legislation

The increase in legislation around PA and ePA has become more prevalent at the state level. The mandates range 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.

ePA (no standard)

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

Standard Form

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

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.

Medicaid and ePA

A recent study indicated specialty drugs account for nearly 33 percent of the total Medicaid drug spend, despite only 0.9 percent of the nearly 75 million Medicaid patients utilizing specialty medications.13, 14

Because non-adherence is a common problem among the Medicaid population, and an increasing number of patients are prescribed specialty medications,5 it’s vital that states latch on to an ePA solution.

A patient with limited resources and extenuating circumstances, such as lack of transportation, is more likely to be non-adherent. Non-adherence could lead to hospitalization, especially for patients on expensive specialty medications, which can ultimately create a costlier burden for states.

An integrated ePA solution could lessen these issues for Medicaid patients and assist with medication readiness and adherence.

Specialty medications account for 33 percent of total Medicaid drug spend. Non-adherence to specialty medications can create an even costlier burden.13, 14

Key Takeaway

Key Takeaway

Currently, government at both the state and federal levels are taking note of the importance of legislation around an electronic solution for prior authorization. With the recent announcement of H.R. 4841, the country is one step closer to aligning on a solution that works for all stakeholders, which will help patients get the medications they need more quickly.