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07 ― Payer Availabilty

Payer integration of ePA functionality helps to ensure all PA requests may be reviewed and determined electronically. Currently, 96% of payers are committed to an ePA solution.

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08 - Pharmacy Availability

For payers, ePA eliminates manual entry of faxed or phoned PA requests, enables payers to receive complete information on initial submission and can facilitate real-time determinations based on payer-specific criteria. Auto-determination functionality helps payers auto-review requests and provide real-time determinations based on preset criteria. In many cases, providers receive the outcome within moments of submission.

Indicating a payer is live with ePA does not mean all medications or plans—in the case of a PBM—use ePA functionality. The majority of payers initially activate ePA for a select number of medications or plans that they service while they work toward electronic incorporation of all criteria, which differs by plan and medication.

Payer Availability?

Percentage of the payer market, representing the majority of market share, committed to an ePA solution.15

Payer Availability Data Representation
Payer Committed Available
Aetna
Anthem
Argus Health Systems
Cigna
Conduent
CVS Health
EnvisionRx
Envolve Pharmacy Solutions
Express Scripts
HealthPartners
HealthSpring
Highmark
Humana
Magellan Rx
Mayo Clinic Health Solutions
MedImpact
Moda Health Plan
OptumRx
Prime Therapeutics

ePA Streamlines the Process for Payers

"We’ve had great feedback from our physicians that it [ePA] drives efficiency."

― Dr. Lynne Nowak, Express Scripts

Vendor Assessment

It is important to understand how an ePA vendor will accomplish key goals needed to successfully complete PA requests. The wrong solution could create administrative waste, cause confusion between stakeholders (payer; pharmacy; provider) and hinder a patient getting the medication they need to be healthy.

How many live integrations does the solution have with payers? Is there an option for submitting forms for health plans that do not offer an electronic solution?

It is important that PA requests can be submitted to any plan in the same ePA solution and workflow. Ideally, the ePA vendor will have a direct, electronic connection with payers representing the vast majority of prescription volume, and the ability to facilitate auto-determinations.

It is equally important to facilitate an electronic workflow for providers that connects with health plans who are not ePA enabled. While the majority of the payer market is working toward ePA availability, there remain lines of business, regional plans and Medicaid and Medicare Part D plans that are not yet live with ePA functionality.

Is auto-determination functionality available through the ePA vendor?

Auto-determination functionality enables payers to set criteria for PA determinations to eliminate manual review. The result is a more efficient process for payers and faster determinations for providers. Electronic prior authorization vendors who offer this functionality should allow full customization of the criteria used to make an auto-determination.

Does the ePA vendor technology support APIs?

The technology for ePA solutions will grow and change with the industry; therefore, API support makes it easier for technology teams at EHR, payer and pharmacy systems to quickly implement new and optimized ePA solutions. Documented, standards-based ePA APIs will be a key to driving adoption in the market.

Key Takeaway

Key Takeaway

Nearly the entire payer industry with leading market share is committed to ePA and are bringing additional lines of business onto their electronic solution. By doing so payers are creating greater access for providers and decreasing turn-around time; however, there is still work to be done for each payer to get every line of business on ePA and increase usage of auto-determination functionality.