Happy providers, happy members. A smooth, hassle-free prior authorization process changes the member experience for the better. CVS Caremark provides clinicians with the information and real-time communication they need from the start—so members get the care they need faster. Learn more.
Not long ago, a big-time US employer approached CVS Caremark with a challenge: Help them find a less complicated approach to prior authorization (PA). The company wanted to pivot from their previous pharmacy benefit manager (PBM) to offer their 170k insured employees a better experience.
In the world of pharmacy benefits, PA is a critical tool that can help manage medication coverage, control trends, and keep treatment affordable. Traditional PA also has a reputation for being cumbersome and complex, causing pain points for members and providers. It doesn’t have to be this way.
So no pressure, right?
CVS Caremark was up to the challenge. Alongside the Caremark team, the employer codesigned a solution to provide a better member experience with automated and proactive email notices. This robust and well-coordinated approach included sharing each type of member communication with the client in advance to allow them to add their voice.
Sounds like a dream, huh? Well, this one’s within reach, with a solution in place that delivers value. The PBM experts at CVS Caremark weighed in on four ways employers can smooth out the PA process, minimize friction, and help improve overall health outcomes. Here’s what you’ve gotta do.
1. Ensure clinical integrity
Members need to feel confident they’re receiving quality care, so improving their experience means proving clinical integrity. Your PBM achieves that through high quality standards, as well as by monitoring and optimizing utilization management (UM) strategies.
Those UM processes are developed by clinicians, supported by medical evidence, and accredited by independent, third-party organizations such as the Utilization Review Accreditation Commission and the National Committee for Quality Assurance. Any approvals or denials of coverage are rooted in rigorous clinical standards, resulting in durable decisions, helping ensure appropriate use, and saving money on high-cost therapies.
2. Create a balanced UM approach
By strategically balancing clinically rigorous UM criteria and costs, plan sponsors get more value. CVS Caremark has the scale and expertise to deliver low net cost at the therapeutic level with formulary strategies, including tools such as preferred drug lists that promote appropriate, cost-effective coverage.
To keep the balance between cost and coverage, specialty guideline management (SGM) helps ensure cost-effective specialty medications for around 60 therapy classes. To do so, it combines clinical assessments, step therapy, a generics-first approach, medical director review for complex therapies, advanced utilization oversight through retrospective case reviews, and day-one UM control. With enhanced SGM, even more stringent PA criteria are applied.
3. Leverage technology
Let’s not forget the importance of technology in connecting providers to health benefits info. CVS Caremark’s investment in electronic health record (EHR) interoperability is a game changer, enabling CVS Specialty to access relevant plan and member data securely and efficiently. Providers can even view real-time benefits information at the point of care to help inform prescribing decisions before the patient even leaves their office.
When providers search for a medication in their EHR or e-prescribing portal, they can instantly:
- know whether the drug is covered and the member’s out-of-pocket cost
- identify up to five lower-cost brand-name and generic alternatives
- see which options require PA or are subject to other UM strategies
And if PA is required, prescribers can submit PA requests electronically, significantly speeding up the process and helping members get started on appropriate therapies—fast.
4. Optimize experiences through digital engagement
The ability to engage members (and their providers) through automated and real-time messaging, as well as data exchange, is invaluable.
The member journey can be confusing and complex. With digital tools on the member’s side, it doesn’t have to be—instead, they can keep in contact with their provider and be informed throughout the process. It makes a huge difference in how they interact with treatment, too, with 95% of CVS Specialty patients digitally engaged with clinicians and care.
From proactive education to updates and notifications on the status of requests for initial or renewing prescriptions, members can get real insight into the PA process. And members can use a secure online portal to access information about the status of their PA requests.
While PA is a standard industry practice, this visibility-first approach takes things to a new level. CVS Caremark streamlines the process to help ease the administrative burden, speed up the decision-making process, and get members started on appropriate therapies faster.
Learn more about how CVS Caremark’s expertise creates happy members.