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Integrated Electronic
Prior Authorization
(ePA) Solutions:
Electronic Health
Records, Pharmacy
Dispensing System
Vendors and Web
Portal Options
About NCPDP
Founded in 1977, NCPDP is a not-for-profit, ANSI-accredited, Standards
Development Organization with over 1,600 members representing virtually
every sector of the pharmacy services industry.
NCPDP members have created standards such as the Telecommunication
Standard and Batch Standard, the SCRIPT Standard for e-Prescribing, the
Manufacturers Rebate Standard and more to improve communication within the
pharmacy industry.
Our data products include dataQ®, a robust database of information on more
than 76,000 pharmacies, and HCIdea®, a database of continually updated
information on more than 2.3 million prescribers. NCPDP's RxReconn® is a
legislative tracking product for real-time monitoring of pharmacy-related state
and national legislative and regulatory activity. www.ncpdp.org
About CoverMyMeds
Founded in 2008, CoverMyMeds is the nation’s largest and most connected
electronic prior authorization (ePA) solution. We help patients receive the
medication they need to live healthy lives by automating the prior authorization
(PA) process, saving health care professionals valuable time and reducing
prescription abandonment.
CoverMyMeds integrates directly within prescriber and pharmacists’ existing
workflows as well as with health plans and payers to allow for near immediate
determinations. More than 700,000 providers and over 49,000 pharmacies
currently process ePA requests through the CoverMyMeds web portal, as well
as via their electronic health record (EHR) or pharmacy system vendor. Our
technology integrates with more than 500 EHR vendors, 80 percent of
pharmacy system vendors and payers representing 75 percent of U.S.
prescription volume. Providers using our solution successfully process more
than 1.6 million PA requests every month. www.covermymeds.com
About HIMSS
HIMSS North America, a business unit within HIMSS, positively transforms
health and healthcare through the best use of information technology in the
United States and Canada. As a cause-based non-profit, HIMSS North America
provides thought leadership, community building, professional development,
public policy and events. HIMSS North America represents 64,000 individual
members, 640 corporate members and over 450 non-profit organizations.
Thousands of volunteers work with HIMSS to improve the quality, costeffectiveness, access, and value of healthcare through IT. Major initiatives
within HIMSS North America include the HIMSS Annual Conference &
Exhibition, National Health IT Week, HIMSS Innovation Center, HIMSS
Interoperability Showcases™, HIMSS Health IT Value Suite, and ConCert by
HIMSS™.
HIMSS Vision: Better health through information technology.
www.himss.org
Matt Brennessel, Manager of Pharmacy
Accounts, CoverMyMeds
Matt’s team is responsible for managing the use of an
electronic prior authorization (ePA) solution for many
of the nation's retail, long-term care and specialty
pharmacy operations. During Matt’s four years with the
CoverMyMeds team, he worked directly with the
nation’s largest pharmacy chains leading successful
implementations, assisting in launching new pharmacy
prior authorization (PA) solutions and helping to grow
CoverMyMeds pharmacy-initiated PA volume from
200k per month to over 1.3 million. Matt is an active
member of NCPDP (National Council for Prescription
Drug Programs), and an adamant supporter of
enhancing pharmacy, patient and provider
experiences in health care through innovation.
Ryan Tarzy, EHR Business Development and
Strategic Partnership, CoverMyMeds
Ryan leads Business Development and Strategic
Partnerships for the Provider vertical at
CoverMyMeds. Ryan has over 15 years of
experience as a founder or executive of digital
health startups. In 2003 he co-founded
MediKeeper, one of the early pioneers in digital
health. He was also the co-founder of Playful Bee,
an early childhood development startup with the
mission of delivering all children to Kindergarten
healthy and prepared for school. Previous to
CoverMyMeds, he served as Senior Vice
President of Business Development for PokitDok
and Vice President of Business Development at
Healthline Networks.
Hemal Desai, President
BestRx Pharmacy Solutions
Hemal is the president and lead developer at
BestRx, a company that provides pharmacy
management software for independent
pharmacies. Hemal has been with BestRx since
2002 where he has been responsible for the
management and development of adding new
features to the BestRx system. Prior to working at
BestRx, Hemal attended undergraduate school at
the University of Illinois at Urbana-Champaign.​
Accreditation Statement
• The Institute for Wellness and Education, Inc., is accredited by
the Accreditation Council for Pharmacy Education (ACPE) as
a provider of continuing pharmacy education. Participants of
the session who complete the evaluation and provide
accurate NABP e-Profile information will have their credit for
1.0 contact hours (0.10 CEU) submitted to CPE Monitor within
60 days of the event. Please know that if accurate e-Profile
information is not provided within 60 days of the event, credit
cannot be claimed after that time.
• ACPE program numbers are:
0459-0000-17-024-H04-P and 0459-0000-17-024-H04-T
• Initial release date is Feb.14, 2017
Learning Objectives
1. Outline best practices for implementing an
integrated ePA solution in your business
2. Articulate how a web portal solution supplements
integrated solutions
3. Identify your system vendor and interpret what an
ePA integration implementation would look like
4. Effectively integrate an ePA solution in your
business
Pre-Test Questions
1. What types of prior authorization management
methods are available to your pharmacy or
practice?
2. What are the main considerations you take when
evaluating a new tool for your pharmacy or
practice?
3. What does your current process for managing PA
look like?
Prior Authorization, Defined
Prior authorization (PA) is a requirement that your physician obtain approval from your
health insurance plan to prescribe a specific medication for you. PA is a technique for
minimizing costs, wherein benefits are only paid if the medical care has been preapproved by the insurance company. PA is typically required due to quantity limits, step
therapy, non-formulary medications and expensive specialty drugs.
Issues with Prior Authorization:
Prior to electronic prior authorization (ePA), a prior
authorization required a fax based workflow to be
completed by the provider and staff. Each health
plan/PBM having their own set of unique requirements.
Impact on Medication Adherence:
40% of medications requiring prior authorization are
abandoned once rejected at the pharmacy
Administrative Waste
More than 50% of providers
indicate that they and their staff
spend up to 20 hours per week
on PA requests
Pharmacists spend an average
of 5 hours per week on PA
requests
Prescriber Costs by the Numbers
Nationwide, physicians spend $37 billion annually interacting with health
plans. Much of that cost is directly related to prior authorization and
medication formulary requirements.
Medication Non-Adherence
Medication non-adherence costs more than $100 billion a year in excess.
Nearly 30% of
prescriptions written
are never picked up
75% of patients fail
to take medications
as prescribed
Abandoned Prescriptions
Recent studies reflect 265 million claims a year result in prior authorization requests.
Based on Frost & Sullivan study
Completion and Turnaround Times
Completion
Turn Around Time
PRE-ELECTRONIC
ELECTRONIC FAX
ePA
15-20 Minutes
3-5 Minutes
Web: 3-5 Minutes
EHR: Seconds
3-5 Days
2-4 Days
Approved: Real-time
Denied: <24 Hours
Electronic Prior Authorization (ePA)
RETROSPECTIVE
PROSPECTIVE
AL L PAY E R
Ability to receive PA
requests started by a
pharmacy
Allows prescriber to start
a PA request in
E-Prescribing workflow
Supports completion of
PA requests for any
health plan or PBM
ePA Workflow: Retrospective
Initiates Request
Completes Request
Call CP!
Electronic
Connection
Pharmacy
Prescriber or Staff
Plan/PBM
ePA Workflow: Prospective
Initiates and Submits
Request at Point of Prescribing Call CP!
Electronic
Connection
Prescriber or Staff
Plan/PBM
Pharmacy
EHR Implementation
Best Practices
EHR Implementation Best Practices
Commit to the three standard workflows that allow
providers to accommodate any type of PA Request
• Prospective
• Retrospective
• Administrative
Determine which style of integration is best for your EHR
• Native Solution
• Embedded Web Solution
PA Dashboard Best Practices
Column Displays
PA Statuses
• Patient Name
• New
• Provider Name
• Sent to Plan
• Medication
• Approved/ Denied
• Date
• Closed
• PA Origin
Cerner EHR Demonstration
eRX
RX Written and PA Created in ePA Worklist
Completing the Request
Request Submitted
Request Determined
Non-Integrated Office Recommendations
How to identify whether your EHR provides an ePA solution?
• Ask your account rep
• Go to https://info.covermymeds.com/prescribers/
What is the best way to have the discussion with EHR
re: their implementation roadmap?
• Talk to your EHR Account Manager
• Make an integration request
Volunteer to be a pilot user
Pharmacy System
Implementation
Best Practices
Step 1: Identify if an ePA
Solution is Available
Your pharmacy system vendor may
already have a free ePA solution.
Resources for verifying:
• Online resources
CoverMyMeds Integrated Systems
CoverMyMeds ePA Scorecard
• Contact Your System Vendor
• Contact Your Switch Vendor
ePA Solution Examples: EasyButton
• Allows pharmacy to
start and deliver ePA
request within current
workflow
• Available for all drugs
and any health plan
• Integrated in 80% of
pharmacy dispensing
systems
ePA Solution Examples: IntelligentPA
Pharmacy receives
PA claim rejection
10-Minute
Resolution Window
OR
Pharmacy resolves claim to cancel PA
notification or manually cancels
IntelligentPA automatically
sends notice to prescriber
Other Best Practices
• Encourage your pharmacy
to offer an ePA solution
• Online Portals
• Contact your switch vendor
• How to become a pilot site
for new solutions
BestRx’s Integrated ePA Story
Road to ePA
• Launched an ePA solution in 2011
• Implemented the solution based on clear pain
points in process voiced by users
• Provides BestRx with competitive advantage by
offering an enhancement to the solution that
streamlines the PA process
PA Pain Points: Pharmacists
• Obtaining proper forms for each plan
• Manually filling out form
• Obtaining prescriber’s fax number/ sending fax
• Follow-up to determine if PA was submitted to plan
• Follow-up with plan to find out if there has been a
determination
• Keeping the patient up-to-date
Benefits of ePA in BestRx:
• No manual data entry
• No need to dig for proper form
• Progress of PA can be followed electronically or via
callback feature
• Makes updating patients less challenging
• Minimal training involved for new techs
• Eliminates need for additional staff
• More time spent helping patients
BestRx Pharmacy System Demonstration
Initiate PA Request
PA Auto-Initiated: IntelligentPA
Claim Reject Notification: IntelligentPA
PA Status Report
Discount Drug Mart
Discount Drug Mart partnered with CoverMyMeds to address the administrative
inefficiencies, delays in therapy, patient frustration and prescription abandonment
caused by the prior authorization (PA) process. They had the following objectives:
AUTOMATE: Initiate a PA request electronically within
Discount Drug Mart’s PioneerRx Pharmacy Software,
which lands in the provider’s hands for completion either
electronically or via fax.
EXPEDITE: Accelerate the PA process in an effort to
decrease the time pharmacists spend on PA requests
and reduce follow-up phone calls to providers.
ADHERE: Decrease time to therapy for the patient by
eliminating manual faxes and phone calls.
Results
PHARMACY UTILIZATION
INCREASE IN ACCESS
FASTER TIME TO THERAPY
Since rollout, 96 percent
actively utilize CoverMyMeds
to manage prior authorization
for medication, with an
average of 60 requests
initiated per month per store.
The rate at which a
provider completed a PA
request electronically
doubled when online
access instructions were
provided and the paper PA
form was withheld.
Patients were able to receive
their medication 50 percent
faster by electronically initiating
a PA request, compared to the
manual process of faxing and
following up by phone.
Post-Test Questions
1. Which of the following is not a current
solution for prior authorization?
a. Fax
b. Patient Submission
c. Pharmacy Software Integration
d. Web Portal
Post-Test Questions
2. True or False: You must have a compatible
EHR or pharmacy system vendor to manage
PA electronically.
a. True
b. False
Post-Test Questions
3. Which of the following ways is the most efficient
method for managing PA?
a. Pharmacist Initiating the request at the time of
claim rejection at the pharmacy
b. Prescriber initiating the request at the point of
prescribing in their EHR or E-Prescribing software
c. Prescriber initiating the request after notification
of claim rejection
Post-Test Questions
4. How can a provider submit a pharmacyinitiated PA request?
a. Via fax
b. Via web portal
c. Via EHR
d. All of the above
Post-Test Questions
5. What is a pharmacy-initiated request called?
a. Prospective
b. Retrospective
c. Interceptive
d. None of the above
Questions?
Save the Date
Best Practices for Electronic Prior Authorization (ePA)
Implementation and Adoption: Eliminating Barriers to
Workflow Integration for Pharmacists and Providers
Tuesday, March 28 | 2:00pm – 1:30pm CT/1:00pm – 2:30pm ET
Although the manual prior authorization (PA) process is outdated, tedious
and filled with overhead expenses, adopting the optimal electronic
method can be challenging, just like implementing any new technology
can be. The last webinar of the series will discuss barriers to changing
pharmacists’ and providers’ normal workflow and strategies for rolling out
a new process in your pharmacy or practice.
Save the Date
HIMSS17
HIMSS’s annual conference and exhibition will be held
February 19-23, 2017. We hope to see you in Orlando. For
more information on HIMSS17, please visit
www.himssconference.org.
NCPDP17 –
40th Anniversary Conference
NCPDP’s annual technology & business conference will be held
May 8-10 in Scottsdale, AZ. For more information, please visit
www.ncpdp.org.