On June 17, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would improve patients’ access to necessary medications by updating the prior authorization process for Medicare Part D, the program that provides coverage for prescription drugs that beneficiaries pick up at a pharmacy counter. The 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 is intended to promote better clinical decision-making and help ensure that patients receive medically necessary prescription drugs. The proposed rule would update the Part D e-prescribing program by adopting standards that ensure secure transmissions and expedite prior authorizations.

Under the proposed changes, clinicians would be able to choose to complete prior authorizations online, reducing burden for providers through a more streamlined process. Clinicians who select the electronic option will typically be able to satisfy the terms of a prior authorization in real time and before a prescription is transmitted to a pharmacy. This is so patients do not arrive at a pharmacy counter only to find that their prescription cannot be filled.

The proposed rule would implement new prior authorization transaction standards for the Part D e-Prescribing program as required by the SUPPORT for Patients and Communities Act. The proposed standards would begin in January 2021. If finalized, all Medicare Part D plans would be required to support electronic prior authorization transaction standards that were developed by the National Council for Prescription Drug Plans (NCPDP).

To read the proposed rule, click here.