Last call for comments on CMS’ ePA proposed rule



The Centers for Medicare and Medicaid (CMS) recently proposed a rule to adopt a transaction standard that would require Medicare Part D payers and prescribers to use electronic prior authorization (ePA) capabilities within their electronic health records (EHRs).

Developed by the National Council for Prescription Drug Programs (NCPDP), the ePA standard transaction supports the electronic transmission of information between the prescriber and payer. Adoption of this proposal would accelerate the reduction of paper/fax/phone prior authorizations (PAs), which burden physicians and their staff, create administrative bottlenecks, and delay time to therapy.  The proposal would also eliminate web portals run by payers or intermediaries.

While mandating the use of a transaction may help push Part D plans to adopt ePA, it may be more problematic for physicians who are having difficulty in identifying which drugs require a PA.  Formulary data in EHRs has been the norm for many years, but the accuracy of the data has come into question.  A number of physicians don’t trust the formulary that they see, and much of the formulary data doesn’t offer the rich depth that it could. 

With the advent of real-time pharmacy benefit information, physicians have access to more timely information after they have made a prescribing choice.  This data, too, can suffer from a lack of critical information like plan alternatives for a restricted-use drug and information on the criteria for approval.

What’s New

The proposed regulation for the use of the standard represents a milestone in electronic prescribing. We believe that facilitating electronic PAs could help doctors make better prescription decisions and increase patient access to medication.

Here’s a summary of what’s new:

  1. Located within EHRs: ePA capabilities will appear within provider EHRs, eliminating the need to visit payer PA web portals or to use other cumbersome PA methods

  2. Standardized process: instead of a separate PA process for each payer, the new ePA standard will present a uniform process, allowing providers to more quickly complete ePA requests

  3. Increased automation: data from within the EHR can automatically be transferred into ePA fields, reducing prescriber time in entering redundant information


While the standard proposed has multiple benefits, there are also some challenges to monitor. Below is our perspective on the benefits and challenges of ePA.


  • Having an ePA standard in place is better than individual, plan-provided ePA portals and processes

  • This standard can save time when patient information is automatically populated into the ePA process using EHRs

  • Prompt ePA decisions bypass lengthy waits for medications and potential non-adherence because of the delay


  • Mandating the use of ePA systems may not be the best way to move the system forward without ensuring PA identifiers are available at the time of prescribing

  • This proposal may encourage health plans to increase their use of PAs as a way to control Rx costs

  • Requiring ePA transactions may not reduce physician administrative time spent on prescriptions if the number of PAs increases

  • The cost of implementing this solution and running ePA checks may exceed CMS’ estimates

  • The PA process may not provide information on the payers’ most cost-effective drug; the source for the payer alternatives remains in formulary data or real-time benefit information


Implementing this capability for the benefit of payers is a step in the right direction, but we believe that more can be done to help patients save on prescription drugs and doctors select the right drug the first time:

  1. Improve formulary data: ensure formulary data shows that appropriate PAs may be needed during the prescription process to help the physician make the right selection the first time

  2. Display alternatives: show relevant alternatives in formulary data and through real-time prescription benefit tools. Ideally, each time a PA requirement is viewed appropriate alternatives, preferably without PA restrictionsa are displayed. These alternatives must be carefully selected so that they are useful for prescription decisions and clinically relevant.

  3. Communicate criteria: inform doctors of criteria for ePA approval through formulary data or the question set to eliminate unnecessary processing

  4. Improve the PA question set: Conceptually, all of the information needed for a PA should be in the patient record and the Part D request for information should be encoded to allow EHR software to fill in all available information automatically leaving only information not present in the EHR to be typed by hand.

  5. Ensure that clinical information is up to date: without keeping formulary information accurate and relevant, ePA capabilities won’t have as much impact

  6. Increase coverage transparency: when patients and doctors have access to understandable coverage information like PA requirements, they can have meaningful conversations to determine the right treatment

By having access to the full spectrum of information, doctors can choose the drugs most suited to their patients’ health and financial needs.

“Incorporation of accurate formulary data and prior authorization and step therapy requirements into electronic health records is critical to ensure that providers have the requisite information at the point of care.” (AMA Prior Authorization and Utilization Management Reform Principles)