Industry Insights

CMS Lays Out Plan to Update PA Requirements for Medicare Part D Program


In an announcement on June 17, the Centers for Medicare and Medicaid Services (CMS) laid out its plan to update prior authorization requirements for the Medicare Part D prescription drug program, which provides coverage for prescription drugs that beneficiaries pick up at a pharmacy.

This proposed rule seeks to reduce healthcare provider burden, while also streamlining access for patients to critical medications. Current standards required under HIPAA (X12 278) do not adequately facilitate electronic prior authorization (e-PA) requests. The proposed change solves for challenges with implementing e-PA and enables clinicians to choose to complete PAs online for Part D prescriptions. Per CMS’ official release, those who select the electronic option “will typically be able to satisfy the terms of a PA in real time and before a prescription is transmitted to a pharmacy.”

Additionally, the rule also proposes new transaction standards for the e-prescribing program, as required under the SUPPORT for Patients and Communities Act. If the proposed rule by CMS is finalized, all Part D plans would need to support these standards to ensure secure e-PA requests and responses.

CMS is accepting comments on the proposed rule until August 16. If the proposed standards are finalized, they would begin in January 2021.

How CMS’ Proposed Rule Impacts the Market

The recently proposed rule from CMS represents an exciting opportunity for the healthcare industry. This is a significant step forward in improving timely patient access to therapy through technology-enabled solutions.

Traditionally, progressing through the PA process has been a major pain point for providers. In fact, one recent study by the American Medical Association (AMA) discovered that 86 percent of providers categorize the burden of PAs is high or extremely high. Further, 88 percent of providers claim the burden has only increased over time.

How CMS’ Proposed Rule Impacts the Market

At AssistRx, our ultimate goal is to transform lives through access to therapy. We approach this commitment understanding the significant burdens placed on providers at multiple phases in the prescribing process, especially in the PA stage, which traditionally causes access delays for patients.

Through our provider platform, iAssist, we’re able to streamline therapy initiation through a variety of acceleration services, including e-PA. As a result, providers benefit from a simplified process while patients gain access to prescribed therapies sooner.
As a company that believes greater access to therapy transforms lives, we are encouraged by CMS’ latest proposal. We are proud to offer best-in-class solutions that can deliver to CMS’ proposal requirements. We look forward to spearheading continued progress in the market through our intentional integration of technology and therapy expertise that informs every touchpoint and simplifies a complex system.