CMS rule would streamline prior authorizations for e-prescribing

Known as the Support for Patients and Communities Act, the rule would improve patients’ access to medications by updating the prior authorization process for the Medicare Part D drug coverage program, which provides coverage for prescription drugs that beneficiaries pick up at the pharmacy counter.

The current prior authorization process requires that providers supply additional clinical information to verify that the medication can be covered under the Medicare Part D benefit. The process also promotes better clinical decision making to ensure patients get medically necessary prescriptions.


Now, the proposed rule would update the Part D e-prescribing program by adopting standards that ensure secure transmissions and expedite prior authorizations.

Also See: AMA survey finds prior authorization trends raise patient risks

If the proposed change is made official, clinicians would be able to choose to complete prior authorization on-line, reducing physician burden via a streamlined process for performing the authorizations.

Doctors selecting the real-time option in most cases will be able to satisfy the terms of a prior authorization in real-time and before the prescription is transmitted to the pharmacy. CMS believes this will ensure patients do not arrive at the counter just to find out the prescription cannot be filled.

If finalized, the new prior authorization transaction standards for Part D e-prescribing would start in January 2021. At that time, all Medicare Part D plans would be required to support electronic prior authorization transaction standards of the National Council for Prescription Drug Plans. The proposed rule is available here.