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Case Study
The prior authorization (PA) process can present patients with unique access challenges, depending on the relative complexity and expense of their prescribed medications. This report details various aspects of the PA process and associated difficulties for patients, along with innovations from CoverMyMeds which can assist patients throughout the medication access journey.
An earlier version of this article included contributions from Austin T. Raper, Ph.D.
Prior authorization for medications continues to significantly impact the U.S. healthcare system. Approximately 11% of prescription claims are rejected at the pharmacy due to PA.[0]2019 ePA National Adoption Scorecard, CoverMyMeds, 2019 As an unintended consequence of PA, patients abandon ~37% of these rejected prescriptions.
Completing a PA request involves the exchange of patient and medication information among providers, pharmacies and payers. When completed manually through phone calls and faxes, the PA process can be inefficient and time-consuming, posing a significant challenge for patients which can lead to prescription abandonment. Fifty-five percent of patients reported delays in therapy due to a medication requiring PA.[0]CoverMyMeds Patient Survey, 2019 In addition, 92% of physicians surveyed said PA can negatively impact patient outcomes.[0]AMA Prior Authorization Physician Survey, American Medical Association, 2019
Prior authorization places a significant administrative burden on providers and their staff. On average, providers and their staff spend approximately two business days on their PA workload each week.[0]AMA Prior Authorization Physician Survey, American Medical Association, 2019 In a survey of providers, 86% indicated the burden of PA is high or extremely high, and 88% feel their PA burden has increased in the last five years.[0]AMA Prior Authorization Physician Survey, American Medical Association, 2019
Pharmacists feel the burden of PA, too. In a survey of pharmacists representing chain, hospital, independent and specialty pharmacies, over half responded that too much of their time is spent on insurance-related activities and see them as a significant barrier to delivering quality patient care.[0]AmerisourceBergen Pharmacy Check-Up: Activities and Barriers to Care Analysis, AmerisourceBergen Corporation and Maru/Matchbox, 2018 The PA process can strain the healthcare system, and the associated fallout can quickly funnel down to patients, potentially driving negative health outcomes.
CoverMyMeds is the industry leader in electronic prior authorization (ePA) – a technology created to mitigate challenges of PA and create efficiencies for all healthcare stakeholders. Our solutions are rooted in technology and supported by the industry’s largest network to best serve patients.
Our resilient technology helps support patients and providers through some of healthcare’s toughest challenges — including the COVID-19 pandemic. In a survey of over 2,700 CoverMyMeds uses, 92% indicated COVID-19 has impacted their work in some way, including large shifts to telehealth.[0]CoverMyMeds Provider Survey, 2020 Nine out of 10 providers also said COVID-19 hasn’t changed the way they process PA requests, indicating a consistent experience despite phenomenal industry shifts.[0]CoverMyMeds Provider Survey, 2020
In this study, we describe various aspects and difficulties of PA and how CoverMyMeds has continually innovated to help patients get the medications they need to live healthier lives.
With CoverMyMeds support, PA requests are auto-populated with patient information and electronically submitted to payers for real-time determination. As claim rejection rates due to PA continue to rise, starting patients on their prescribed therapy is more difficult than ever.
For several top-prescribed therapeutic classes,[0]Medicine Use and Spending in the U.S., A Review of 2017 and Outlook to 2022, IQVIA Institute, 2018 claim rejection rates can be as high as 45% – leaving many patients without their medication.[0]CoverMyMeds data on file, 2019 By creating efficiencies throughout the PA process, CoverMyMeds has helped patients get the medications they need over 200 million times.[0]CoverMyMeds data on file, 2020
In a recent study, pharmacists asked nearly 200 patients why they failed to pick up prescriptions during a given time frame.[0]Implementation of a community pharmacy workflow process to identify and follow up with prescription abandonment, Journal of the American Pharmacists Association, 2019 The most common reason cited by 32% of respondents was they forgot — exceeding factors like cost, transportation issues and non-compliance. The data suggests if prescriptions are available for pick up sooner, patients may be less likely to forget their medication and more likely to remain adherent.
When providers completed PA requests by fax and phone, turnaround times for determinations were delayed by a full day, resulting in no medication dispense. In contrast, many ePA requests through CoverMyMeds received auto-determinations, allowing for immediate dispense of most medications.[0]CoverMyMeds data on file, 2019 65% of prescriptions with a completed ePA request were dispensed within 1 hour.[0]CoverMyMeds data on file, 2019
Note: Data is limited to medications dispensed with a corresponding PA approval from Dec. 2017 - Nov. 2018. For ePAS, autodetermination is possible, which can allow for immediate medication dispense.
Busy schedules and heavy workloads can make it difficult for provider offices and pharmacies to keep track of fax and phone PA requests. With CoverMyMeds, ePA requests auto-start at the pharmacy for the provider to complete. All PA requests are centralized in a single location to streamline the provider workflow. As a result of improved workflows and support, CoverMyMeds can help more PA requests make it to the health plan for a determination.[0]CoverMyMeds data on file, 2019
When a brand is not supported through CoverMyMeds and a script for that brand is rejected at the pharmacy due to PA, our solution surfaces formulary alternatives to help get the patient on a clinically appropriate therapy. This can present providers and pharmacists with the opportunity to switch the prescription to an approved alternative to help the patient begin treatment more quickly. In 2019, 62% of PA requests were started at the pharmacy, and formulary alternatives were sent to providers for brands not on program.[0]CoverMyMeds data on file, 2019
When a brand is on program with CoverMyMeds and a script for that brand is rejected at the pharmacy due to PA, a brand-specific PA request is initiated at the point of claim rejection and is sent to the provider for completion. This streamlines the provider workflow and helps reduce the risk of switching or abandonment due to PA. With this added support, the patient can remain on their originally prescribed therapy.
As CoverMyMeds helps improve the prescribing experience over time, the number of PA requests sent to the plan for determination per provider can increase.[0]CoverMyMeds data on file, 2020 By improving the messaging the provider receives from the pharmacy, PA request submission per provider nearly doubles.[0]CoverMyMeds data on file, 2020
CoverMyMeds helps support patient medication adherence for brands on program by auto-starting PA renewals when they are due to expire. Initiating renewals helps reduce gaps in therapy and creates a seamless patient experience. On average, the approval rate for renewals is 24% higher than initial PA requests for the same brand.[0]CoverMyMeds data on file, 2020
CoverMyMeds combines technology and expert human intervention to give providers visibility throughout the entire PA process, delivering support when PA requests require additional action to make it to the health plan for determination. Additionally, if the health plan denies a claim, CoverMyMeds can assist providers through the appeal process. Live support and automated PA follow up provide a safety net to help patients get their prescribed medications, while also helping improve the prescribing experience.
High claim rejection and PA denial rates can give providers the perception that a medication is difficult to prescribe. A poor prescribing experience may prompt providers to switch to an alternative medication, despite preferring the original drug. With expert PA support, CoverMyMeds guides providers through the PA process and helps ease challenges.
With enhanced CoverMyMeds support, the submission rate per provider increases by 84%, on average, for sponsored brands.[0]CoverMyMeds data on file, 2020
Busy provider schedules and heavy office workloads can delay turnaround time for determinations or allow PA requests to slip through the cracks completely. By enhancing visibility into PA status, providers are notified when a PA request requires action. With automated reminders and follow-up support, CoverMyMeds helps pull-through more PA requests to completion.[0]CoverMyMeds data on file, 2019 21% more PA requests, on average, are sent to the plan for determination.[0]CoverMyMeds data on file, 2019
Additionally, expert support and review helps ensure PA requests are error-free and contain all the necessary information for a plan determination. Health plan determination approval volume nearly double when providers submit thorough PA requests at a higher volume, increasing by 93% for medications with retail, specialty and mixed distribution models.[0]CoverMyMeds data on file, 2020
PA requests can be denied for a multitude of reasons. In many cases, requests may be incomplete, filled out incorrectly or require additional supporting information. For PA requests with a known outcome, denial rates are 30% on average, leaving many patients without their medication.[0]CoverMyMeds data on file, 2019
CoverMyMeds can assist providers by identifying why requests were denied and securing necessary information to help increase the likelihood of redetermination. With the support of CoverMyMeds, 17% more appeal submissions proceed to the health plan, on average.[0]CoverMyMeds data on file, 2020 As a result of increased appeal submissions, health plans overturn more denial determinations.
Through CoverMyMeds, the success rate for appealed denial determinations is 51% on average — underlining the value of expert assistance for the complicated PA process.[0]CoverMyMeds data on file, 2020
To help patients afford their medications, manufacturers can offer patient assistance programs or copay cards to offset out-of-pocket expenses. However, copay cards often have maximum limits which can vary by medication. Unless patients obtain insurance coverage while using a copay card, they may be subject to high out-of-pocket costs after reaching the card’s limit, which may lead to medication non-adherence.
Recent data shows that as out-of-pocket expenses increase, patients are more likely to become non-adherent to their prescribed therapies, with 69% abandoning prescriptions when out-of-pocket costs rise above $250.[0]Patient Affordability Part Two: Implications For Patient Behavior & Therapy Consumption, IQVIA Institute, 2018
By automatically starting a PA request the first time a patient uses a copay card at the pharmacy, CoverMyMeds helps patients obtain medication coverage by their health plan for the next prescription refill. As a result, patients can remain on their originally prescribed therapy and avoid drug switches or gaps in treatment.
Verifying insurance coverage and completing PA can be time-consuming, but copay cards can start a patient on their prescribed medication and reduce time to therapy by covering the first fill. However, if a PA is not submitted to the patient's insurance plan before subsequent refills, they may experience high out-of-pocket expenses upon reaching the copay card limit and consider switching to a less expensive alternative.
Starting a PA request the first time a patient uses a copay card at the pharmacy allows insurance coverage to begin seamlessly and more patients are able to remain on their originally prescribed therapy helping to cement brand loyalty. Following PA request approval, the cost to the manufacturer copay card program may decrease.[0]CoverMyMeds data on file, 2019
PA process difficulties can vary based on the complexity and expense of prescribed medications. Together, CoverMyMeds’ solutions can address unique access challenges for any medication.
By helping patients get the medications they need, CoverMyMeds can help bring value to all healthcare stakeholders. This value has encouraged growth of a network consisting of over 750,000 active providers, payers representing 94% of prescription volume, 96% of pharmacies, integration with 75% of EHRs and over 200 life science brands.
Learn how to become part of the CoverMyMeds network by visiting go.covermymeds.com/solutions