On June 17, 2019, CMS released a proposed update to the transaction standard for the Medicare Prescription Drug Benefit Program’s (Part D) e-prescribing program (Proposed Rule). Specifically, the Proposed Rule would require all Part D plans to support electronic prior authorization transaction standards that were developed by the National Council for Prescription Drug Plans (NCPDP) to ensure secure electronic Prior Authorization (ePA) transactions between prescribers and Part D plan sponsors no later than January 1, 2021.

Under the Proposed Rule, Part D plan sponsors will be required to support NCPDP SCRIPT standard version 2017071 for ePA transactions and will be required to use that same standard when performing ePA transactions for Part D-covered drugs prescribed to Part D-eligible individuals. In its press release, CMS stated that the proposed use of the NCPDP SCRIPT standard would promote “better clinical decision-making” and would “ensure that patients receive medically necessary prescription drugs…by adopting standards that ensure secure transmissions and expedite prior authorizations.” Through the updated e-prescribing standards, clinicians would be able to complete prior authorizations online.

According to CMS, the use of an ePA transaction standard would allow prescribers using an electronic prescribing (eRx) system or an electronic health record (EHR) with eRx capability to instantly be able to determine whether the beneficiary’s plan requires a prior authorization for a given medication. For instance, if a prescriber enters the prescription information for the Part D eligible medication into the eRx system, a message would be returned to the provider indicating whether a prior authorization is required. Use of the ePA transactions would thus enable prescribers to know both whether additional information is required and also allow prescribers to fulfill the terms of the prior authorization at the same time.

CMS’s press release on the Proposed Rule notes that “clinicians would be able to choose to complete prior authorizations online, reducing burden for providers through a more streamlined process for performing prior authorization for Part D prescriptions.” Moreover, clinicians who select the electronic option will typically be able to satisfy the terms of a prior authorization in real time and before a prescription is transmitted to a pharmacy. This is so that “patients do not arrive at a pharmacy counter only to find that their prescription cannot be filled.”

Due to the proposed adoption of the new standard, CMS is seeking comment on various aspects of the Proposed Rule including:

• The proposed adoption of the NCPDP SCRIPT standard version 2017071 eRx for ePA transactions for Part D covered drugs prescribed to Part D eligible individuals;
• The impact of these proposed transactions and the proposed effective date on industry and other interested stakeholders, including whether the implementation of a NCPDP SCRIPT standard version 2017071 ePA transaction standard for use by prescribers and plans in the Part D program would impose an additional burden on the industry as a whole;
• Whether the proposed date of January 2021 for implementation would be feasible;
• Strategies to mitigate burden in order to support successful adoption of this policy; and
• Ways CMS can support plans as they transition to the ePA standard by the 2021 deadline.

The Proposed Rule is available in its entirety here. CMS’s press release can be found here. Comments on the Proposed Rule must be received by CMS by August 16, 2019 and may be submitted electronically here.