AMCP Issues Commentary to CMS on Making PA Processes More Efficient

A pharmaceutical sciences graduate from St. John’s University, Ellen Scharaga is an operational consultant at Alegria Specialty Pharmacy. Dedicated to improving her practice, Ellen Scharaga is a member of the Academy of Managed Care Pharmacy (AMCP).

AMCP is a professional association dedicated to improving patient access to affordable medicine and bettering health outcomes. The association regularly advocates on behalf of managed care pharmacies to ensure their members are considered in federal and state healthcare policy making. In August 2019, for example, AMCP provided comments to the Centers for Medicare and Medicaid Services (CMS) on methods to reduce the administrative burden occasioned by prior authorizations (PAs). The objective of the commentary was to give CMS the perspectives of managed care pharmacies on how to prioritize patients over paperwork.

PA is needed when certain drugs or treatments not covered by a patient’s insurance carrier are recommended to the patient. The patient’s doctor requests coverage of these drugs from the insurer, and if approved, the drugs are covered. It is a tool that ensures patients receive established drugs proven to be safe and effective.

In its commentary to CMS, AMCP recommended advancing tools to help clinicians make better decisions in the PA process and to fine-tune PA programs to prioritize the patient experience. It also urged managed care organizations to implement information technologies for electronic prior authorization (ePA), which would make PA processes less paper-intensive and more efficient. Furthermore, AMCP encouraged managed care organizations to work closely with healthcare providers in the PA process, providing advanced notice of formula changes, avoiding broad PA requirements for drug therapies used in emergency care, allowing timely PA approvals for necessary exceptions, and handling denial appeals expeditiously.