CMS Proposes Electronic Prior Authorization for Part D Drugs

CMS is proposing to update electronic prescribing standards for the prior authorization process for Medicare Part D that it said would expediate access to necessary medications.

Under the new standards, which would also ensure secure transmissions, clinicians would be able to complete prior authorizations online through a more streamlined process. According to CMS, clinicians who choose the electronic option should expect to be able to satisfy prior authorization requirements in real time before the prescription is sent to a pharmacy. CMS believes the rule would ensure that patients don’t find out their prescription cannot be filled once they reach the pharmacy counter.

“Improving patients’ access to prescription to prescription drugs is a top priority for CMS,” said CMS Administrator Seema Verma in a statement. “This proposed rule would reduce the time it takes for a patient to receive needed medications and ease the prescriber burden by giving clinicians the flexibility and choice to complete prior authorization transactions electronically.”

The current prior authorization process has served as a pain point for physicians, who currently have to follow a manual process through phone calls or faxes. A 2018 physician survey conducted by the American Medical Association found that according to 1000 physicians, prior authorizations delay care, have a significant negative impact on clinical outcomes, and place a high burden on providers.

According to CMS, if the proposed rule is implemented, this current system will be eliminated. The rule will not impact the prior authorization criteria that Part D plans have in place.

The proposed rule, which would take effect January 2021, would implement new prior authorization transaction standards for the Part D e-Prescribing program as required by the SUPPORT (Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment) for Patients and Communities Act, which was enacted in October 2018. If finalized, all Part D plans would be required to support the new standards, which were developed by the National Council for Prescription Drug Plans.

CMS estimates that the one-time cost for implementing the necessary changes to support these new transaction standards will average $100,000 and will vary based on the size and expertise of the plan.

The agency is accepting comments on the proposed rule until August 16.