The primary goal of prior authorization at CarelonRx is to help provide access to timely, evidence-based patient care. By seamlessly integrating members' medical and pharmacy claims, we’ve implemented Proactive Prior Authorization (Proactive PA) to enhance efficiency and optimize the healthcare experience for members and their care providers.
Understanding Prior Authorization
A recent study by JAMA concluded that approximately 25% of healthcare is wasteful and unnecessary.1 Recognizing this challenge, we’re continually refining our processes to add value for our members. We believe that the Prior Authorization (PA) process is essential to help ensure evidence-based use of drugs and therapies resulting in better health. However, it is often perceived as cumbersome and time-consuming. For a deeper understanding of the role of PA in pharmacy care, see the article, Prior Authorization: burden or benefit?
Proactive PA: Member-centered clinical enhancement
Our Proactive PA seamlessly integrates member medical claims and pharmacy data to automatically approve PA requests. This approach prioritizes the plan member, using their own relevant data such as health history and diagnosis codes, to foster connected care between pharmacies, care providers, and healthcare professionals. Proactive PA also helps promote clinically superior drugs, further improving health.
Key benefits of Proactive PA
1. Promotes health and safety.
- Helps ensure evidence-based, clinically appropriate use of drugs and therapies.
- Helps promote clinically superior drugs, contributing to better health.
- Helps prevent use of drugs and therapies with unproven evidence of clinical benefit, protecting members from potential harm.
2. Improves member and provider experiences.
- 35% Reduction in clinically processed prior authorizations, due to proactive approvals.2
- Reduces administrative work for providers.
- Integration with electronic Prior Authorization (ePA) ensures faster, nearly real-time approvals.
For instance, a patient with Type II diabetes can receive medication quickly when criteria such as medical history and treatment compatibility are met. This minimizes delays usually associated with manual reviews and approvals, directly impacting patient satisfaction and adherence to therapy.
3. Helps lower cost of care.
- Avoids waste and errors.
- 68% avoidance of off-label GLP-1 diabetes drug use by non-diabetics, resulting in $0.45 PMPM cost avoided.3
4. Supports many common therapeutic categories, including:
- Drugs to treat cancer.
- Drugs to treat diabetes.
- Drugs to treat attention deficit hyperactivity disorder (ADHD).
Transformative approach to prior authorization
Ultimately, Proactive PA greatly benefits patients by ensuring they access clinically appropriate medications without delays, leading to better health outcomes and increased satisfaction with their pharmacy benefits. For care providers, it means reduced administrative burdens and more time dedicated to patient care. Employers offering pharmacy benefits experience lower total care costs while maintaining high-quality healthcare options for employees. The process streamlines drug approval challenges and boosts overall satisfaction among plan members.
Engage with your CarelonRx representative to explore how Proactive PA can support your organization’s pharmacy benefit plan objectives—enhancing efficiency and patient care while effectively controlling costs. Reach out to connect with us.
1 Shrank WH, Rogstad TL, Parekh N. Waste in the US Health Care System: Estimated Costs and Potential for Savings. JAMA. 2019;322(15):1501–1509. doi:10.1001/jama.2019.13978.
2 CarelonRx internal data, 2023; 2024.
3 CarelonRx internal data, 2023.
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