When a member receives a prescription, everyone involved shares the same goal: helping that person access the right medication as quickly as possible. For prescribers, that means spending less time on administrative tasks and more time caring for patients. Across the health care system, it also means helping ensure treatments are used appropriately while supporting access to care. Prior authorization plays an important role in helping achieve those goals.
Prior authorization helps ensure medications are prescribed consistent with clinical guidelines and coverage requirements. As treatment options continue to expand, particularly in specialty pharmacy, the process supports evidence-based care while promoting compliance with benefit plan formularies.
At the same time, health care is becoming increasingly complex. A recent CVS Caremark and Employee Benefit News (EBN) study, The state of pharmacy management, found employers remain highly concerned about rising prescription drug costs, yet only 30% believe they have significant influence over pharmacy spending. Employers are increasingly looking for support in managing pharmacy benefits, improving access to medications and simplifying the health care experience for the people they serve.
How CVS Caremark is streamlining prior authorization
As health care becomes more complex, prior authorization processes are evolving as well.
One example is CVS Caremark’s work to streamline the review process while maintaining rigorous clinical standards. Enhancements to prior authorization workflows have helped reduce the median review time to approximately 12 minutes. In addition, nearly 4 million prior authorizations have been approved real time, helping members receive faster decisions and reducing delays in care.
A second example can be found in specialty medications, where medications used to treat chronic, rare and complex conditions often require additional clinical reviews. To help simplify the experience, CVS Caremark recently expanded its use of Touchless Prior Authorization for select specialty medications. The solution connects directly with electronic health records where available and approved to retrieve the clinical information necessary for review. When required criteria have already been met, approvals can occur automatically, reducing manual steps and accelerating access to coverage.
CVS Caremark has expanded this capability to additional specialty medications including Vivitrol and Epidiolex, treatments used for substance use disorder and epilepsy. In some cases, approvals can occur in as little as 22 seconds, helping members begin therapy sooner while reducing administrative burden on prescribers.
What’s next for prior authorization
These kinds of improvements are becoming increasingly important as specialty medications continue to account for a growing share of pharmacy spending and treatment innovation. New therapies are creating opportunities to improve outcomes for many members, but they can also involve complex clinical and coverage considerations.
Prior authorization remains an important component of modern health care as new therapies continue to emerge. The opportunity ahead is to continue to improve the process.
By reducing unnecessary complexity, accelerating decisions and helping members start treatment sooner, health care organizations can help more people access the care they need when they need it, creating a better experience for members, prescribers, and plan sponsors alike.
