Policy Examples

• Prior authorization is a process through which a request for coverage of a benefit or service is submitted to an insurance company or its contractors for review before the item is furnished to the patient and before the claim is submitted for processing. source
• In 2019 Arkansas Act 964 was signed into law “requiring all health insurers and the Arkansas Medicaid program to remove prior authorization to FDA-approved medications that have been shown to support recovery, reduce health care costs and save lives, including buprenorphine, methadone and naltrexone.” source

Outcome Evidence

• Electronic prior authorization (ePA) led to faster turnaround times and higher dispense rates, according to new CoverMyMeds data. More than 60% of ePA requests received a determination in less than two hours compared to 0% of PA requests done over the phone or fax — and they led to an 80% higher dispense rate. source
• Just over 20% of physicians said their electronic health records (EHRs) allowed for electronic approval, which can be more efficient. The Council for Affordable Quality Healthcare estimates ePA can save $6.84 per transaction. source & source
• In 2017, the New York Attorneys General worked with payors to reform prior authorization for substance use disorder treatment. The Attorneys General revealed Empire BlueCross Blue Shield denied almost 8 percent of medication-assisted treatment coverage requests in 2015 and the first half of 2016. source
• The 2018 American Medical Association Prior Authorization Survey found that 65% of providers wait at least one business day for a decision and 26% wait at least three business days. 28% of providers responded that the prior authorization process led to a serious adverse event. Additionally, the survey finds the number of prior authorization requirements has increased in the past five years and 85% of physicians say the practice interferes with continuity of care. source
• The Medicare Prior Authorization of Power Mobility Devices (PMDs) Demonstration began on September 1, 2012 in seven states and later expanded to 12 states. Between 2012 and 2016 the number of beneficiaries receiving a PMD in the 12 demonstration states decreased by 67.4% and decreased 60% in non-demonstration states. source