CompletEPA® Updates to PBM and Payer Formulary Files
Released by Surescripts on 8/31/16
Updates to PBM and Payer Formulary Files to Drive an Improved User Experience
As electronic prior authorization usage increases across the network, PBMs and payers now have better visibility into the drugs that are flagged for PA and the prescribing patterns for those drugs. This allows PBMs and payers to continuously make formulary adjustments for drugs that may not require the PA flag or to move general PA flags to more specific coverage restrictions (i.e. quantity, age, gender, etc.).
By making these improvements, prescribers will have increased confidence in the data being presented to them and will be able to complete more electronic prior authorizations prospectively and within the e-prescribing workflow.
Recent changes to formulary coverage files include OptumRx, who has taken, this opportunity to provide PA flags for all of its commercial plans. Prescribers will now see additional formulary detail for plans that previously may have lacked coverage information.
In order to take advantage of these formulary improvements, it is important that prescriber vendors download updated OptumRx formulary files as soon as possible and ensure that updates are running at regular intervals to capture any changes as they are made.
For more information regarding network requirements for formulary downloads, please reach out to your Surescripts Account Manager or Activation Manager for assistance.
CompletEPA: Taking the Pain Out Of Medication Prior Authorization Webinar Now Available ON DEMAND
Surescripts bi-weekly webinar CompletEPA – Taking the Pain Out of Medication Prior Authorization is now avalaible on YouTube; (link included below).
The streamlined version of the webinar provides a great introduction to electronic prior authorization and can be shared with all health care professionals.
If you are interested in coordinating a user specific webinar for your organization, please reach out to your Surescripts Activation Manager or Account Manager.
Using CompletEPA to Process Medication Prior Authorizations Helps Avoid Completing Unnecessary Forms
PBMs and health plans report that approximately 30% of submitted prior authorization forms are for medications that did not actually require a prior authorization.
CompletEPA saves providers time by leveraging the NCPDP SCRIPT standard and provides the provider or clinical staff with a prior authorization question set or indicates that additional clinical information is not required in a matter of seconds (median response time is currently 3-7 seconds).
One Surescripts Customer reports that they are saving on average four FTW weeks with CompletEPA. They attribute the savings to a shift in how medication prior authorizations are being handled now as opposed to how they had been processed in the past – using faxing, phone calls, and online web portal solutions.
Hear how one of our customers has further streamlined their workflow and taken advantage of the efficiencies offered by CompletEPA by clicking the link below.
HIMSS Electronic Prior Authorization Webinar
PBM/Payer Reason Code “CO”
Description: The receiver is not the prior authorization processor for this patient
Sample PA Notes from PBM:
• PBM does not manage PA for this client. Please call 800-555-5555 for coverage review.
• PBM is not the PA processor for this patient.
Next Steps: The provider or clinic staff should refer to the instructions provided in the PANote field.
For those organizations that have included access to Third Party Processing and PDR in their integration of CompletEPA Surescripts will attempt to find the third party processor in the event that the patients PBM does not process PAs for the patients health plan or payer. If a third party processor cannot be identified Surescripts will return an editable PDF via our connection to PDR.
PBMs Live in Production:
• CVS/Caremark
• Express Scripts
• Navitus
• MedImpact
• OptumRx
• Argus
• EnvisionRx
Directly Connected Health Plans:
• HealthPartners Health Plan via MedHok
If you need more information about live PBMs or health plans and their associated Payer IDs please pull the most recent version of the Surescripts Organization Directory.
For additional assistance in obtaining a current copy of the Surescripts Organization Directory please log a support case with Surescripts Customer Support.
Webinar: CompletEPA® – Taking the Pain Out of Medication Prior Authorizations
Topics addressed during the webinar include:
• Value of CompletEPA to the practice and patient
• Simplified workflows, including 3rd party PA processors and PDR connectivity
• CompletEPA product demonstration
• How to get access to CompletEPA
Come with your questions and see how CompletEPA can benefit your organization.
These webinars are open to all healthcare professionals and are held every other Wednesday at 4:15 p.m. Eastern Time.
Please feel free to forward this webinar to anyone within your organization whom you feel would benefit from the information. You are also encouraged to pass along the webinar to your end users as a way to drive awareness of CompletEPA and its benefits.
If you have any questions regarding CompletEPA® Accelerator, please contact your Surescripts account manager.