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CMS proposes prior authorization update for Part D drugs

The expedited process and drug access would allow clinicians to complete the process online under new e-prescribing standards.

Susan Morse, Managing Editor

The Centers for Medicare and Medicaid Services has issued a proposed rule updating the prior authorization process for Medicare Part D coverage of prescription drugs picked up at the pharmacy counter.

Under the proposed change, clinicians would be able to choose to complete prior authorizations online. The rule would update the Part D e-prescribing program by adopting standards to ensure secure transmissions and expedite prior authorizations.

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.


Clinicians who select the electronic option will be able to satisfy the terms of a prior authorization in real time and before a prescription is transmitted to a pharmacy.

This means a patient can arrive at the pharmacy counter knowing their prescription can be filled.


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, CMS said.

But prior authorization can also slow down the process of patients getting needed medications and adds an additional step for clinicians.


"Improving patients' access to prescription drugs is a top priority for CMS," said CMS Administrator Seema Verma. "This proposed rule would reduce the time it takes for a patient to receive needed medications and ease the prescriber burden by giving clinicians the flexibility and choice to complete prior authorization transactions electronically."

Twitter: @SusanJMorse
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