Prior Authorization (PA) is an important component of the CarelonRx whole-person approach to care. Prior Authorization is the process by which we approve a drug before it is dispensed to a member. It lets us use evidence-based medicine and consider the full impact of a given care decision to help improve a member’s health, maximize clinical benefit, avoid clinically inferior drugs, and minimize a member’s exposure to unnecessary health risk.

Unfortunately, Prior Authorization has negative perceptions.

Certainly, there have been some complaints about the traditional Prior Authorization process. Some have found it cumbersome and time consuming at a time when plan members have a low tolerance for delays.

Reducing wait time

That’s why CarelonRx is dedicated to fast-tracking decisions regarding drug treatments so they can be made as early as possible, based on the latest clinical evidence.

Our electronic Prior Authorization process is integrated with electronic medical record data. It’s the fastest, easiest way to submit and receive Prior Authorization reviews and determinations.

In fact, our system can automatically complete a Prior Authorization when we identify a required medical diagnosis in our medical claims system. Further, we use predictive analytics to automate the utilization review process in real-time. Members and health care providers, alike, can even submit a Prior Authorization for approval before a prescription is sent to a pharmacy. If approved, the pharmacy claim then pays without interruption.

Timely reviews

Because we’re committed to connecting members with the care they need, CarelonRx reviews our clinical criteria annually—with quarterly updates for any new clinical evidence. In addition, we identify drug services, therapies, or treatments with high approval rates to determine if a Prior Authorization requirement should be removed.

Putting members first

By simplifying the Prior Authorization process, we can help lower members’ out-of-pocket costs by ensuring they receive clinically appropriate medications and deliver significant cost-savings to providers by reducing time spent on Prior Authorization transactions. But, perhaps most importantly, our process offers timely, clinically appropriate care to members with minimal disruptions.

Get the latest news from CarelonRx