Prior Authorization (PA) serves as a cornerstone in ensuring that prescribed medications are both clinically appropriate and necessary. This process requires health plan approval before dispensing medication, aligning treatments with evidence-based standards. PA effectively maximizes clinical benefits, minimizes unnecessary health risks, and promotes cost-efficient medication usage.
Why do prescriptions need prior authorization?
Despite its advantages, misconceptions about Prior Authorization persist, with it sometimes perceived as more of a hindrance than a help to patient care. It's important to understand that PA is not intended to be a barrier to care. In fact, the PA process works to:
- Ensure members receive the right medications for their condition at the right time.
- Help avoid waste by preventing the use of clinically inferior or unnecessary treatments.
- Confirm prescriptions are aligned with the latest evidence and clinical guidelines for specific conditions.
At CarelonRx, we have consistent clinical criteria regardless of where the drug pays (pharmacy or medical benefits).
Advancing the PA process end to end
Complaints about the PA process often stem from perceptions of it being cumbersome and time-consuming. However, the integration of electronic Prior Authorization (ePA) within electronic medical records (EMR) has significantly streamlined this process, facilitating quicker decision-making. Authorization issues can often be resolved promptly and automatically when medical diagnoses align with claim data.
Reducing wait time for prescription approvals
Reducing wait time remains a priority for CarelonRx — that’s why we work to fast-track drug treatment decisions using the latest clinical evidence. A crucial element is our own ePA process, to offer care providers a swift way to submit and receive reviews and determinations.
Our system can automatically complete a PA when a required diagnosis is found in our claims system. Through predictive analytics, the utilization review process operates in real-time. Members and providers can submit requests even before prescriptions reach pharmacies, ensuring seamless processing of pharmacy claims.
Enhancing members' experience
By prioritizing prompt access to necessary treatments, we enhance the patient experience while maintaining clinically sound and evidence-based care decisions.
CarelonRx is committed to efficiently connecting members with the medications they need. We also avoid use of drugs where evidence tells us the drugs provide no (or minimal) clinical benefit and yet the drug is priced irrationally high, causing waste.
We fortify reviews and approvals through ongoing assessments and frequent clinical criteria reviews — conducted annually with quarterly updates — to identify and optimize drug services and therapies.
Putting members first for better outcomes
Prior Authorization ensures that patients receive timely and clinically appropriate care with minimal disruption. Look behind the misconceptions and you’ll see that maximizing clinical efficacy, improving health outcomes, and reducing unnecessary health risks and costs is the real purpose of PA.
At CarelonRx, PA serves as a safeguard that places members' wellbeing at the forefront, transforming what could otherwise be a burden into a significant benefit.
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