Criteria Builder, powered by CoverMyMeds

A Powerful Engine For Managing PA Guidelines & Determination Logic

Criteria Builder

As part of CoverMyMeds’ end-to-end prior authorization (PA) solution suite, Criteria Builder allows payers to develop and manage PA guidelines within their utilization management program.

Criteria Builder Benefits

Reduce Additional Outreach

Reduce follow-up to providers by using dynamic question logic to gather relevant clinical information up front.

Improve efficiency

Reduce the manual effort and redundancy associated with maintaining paper-based drug guidelines.

Create Consistency

Implement a single source of guidelines across electronic, phone and fax channels.

Review Faster

Use automatically generated visual decision trees with recommended outcomes to make the PA review process easier.

Increase Speed to Therapy

Helps members get their needed therapy faster with determination logic and outcome reasons that result in a shorter approval duration.

CoverMyMeds' Central features

Key Features

Built‐in logic to support recommended outcomes and auto‐approvals

Single solution for management of all UM rules, drug sets and outcome reasons across plans and formularies

Easily apply and expire guidelines at a specified future date

NCPDP SCRIPT Standard compliant clinical questions for easy ePA integrations