October 2015

National Adoption Scorecard

Electronic Prior Authorization (ePA)

This report summarizes the current state of the electronic prior authorization (ePA) industry. The intent is to quantify current ePA adoption rates, highlight implementation status by market share leaders, and outline the keys to success for ePA in the industry.

The ePA National Adoption Scorecard is written and published by CoverMyMeds® with guidance from industry experts on the ePA National Adoption Scorecard Advisory Board:

Lee Ann Stember
NCPDP, President

Matt Moore
Cerner Corporation, Senior Strategist, Clinical Solutions Management

Nick Calla
Cardinal Health, Vice President, Industry Relations

Rebecca Snead

Adam Kautzner
Express Scripts, Vice President Formulary
& Drug Trends

Doug Gray
VA Association of Health Plans, Executive Director

These stakeholders work together to address pharmacy industry interests and support initiatives that improve patient health care. NASPA supports leadership, sharing, learning and policy exchange among its members and pharmacy leaders nationwide.

NASPA and its members remain actively involved in advocacy and educating state and federal legislators and agency personnel on health care related issues that are critical for providers and pharmacists, but most importantly, patients. A few of the issues addressed recently include:

  • Collaborative Practice Agreements
  • Combating Rx Abuse
  • Immunizations
  • Specialty Drugs and Specialty Pharmacy
  • E-Prescribing
  • Electronic Prior Authorization (ePA)

As a pharmacist and advocate for the industry, specifically an advocate for the patient, I have seen the frustration from all parties when a prescription is denied due to cumbersome policies and procedures related to prior authorization. While the intent of prior authorization (PA) is warranted, the archaic, paper process causes undue administrative waste for health care professionals and delays patient treatment. Often, the result is prescription abandonment, which ultimately results in additional costs to the health care industry.

The need for ePA is real and now is the time to implement a streamlined, electronic PA process. This report, which my peers and I have provided feedback and guidance on, outlines the status of ePA and the steps necessary to successfully implement ePA across the industry.

My involvement in the ePA National Adoption Scorecard represents my commitment to improving the PA process through electronic prior authorization.

We hope you will join us in moving the industry toward 100% ePA adoption.

Executive Summary

The ePA National Adoption Scorecard details the current state of electronic prior authorization (ePA). The Scorecard follows the increase in ePA availability in electronic health records (EHR) systems with payers and at pharmacies, which represent the majority of the market share. The original ePA National Adoption Scorecard report was published in March 2015; it is updated and republished semiannually.

In addition to availability updates, this release of the report includes new information on ePA legislation by state.


The ePA National Adoption Scorecard compiles data from several publications as listed in the sources section of this report. Availability data is based on public announcements as well as direct communication from companies. Where noted, CoverMyMeds' connections to more than 360 EHRs, all payers, and 45,000 pharmacies, is used to supplement and advise key takeaways.

Companies interested in working with the CoverMyMeds research team, or updating report data, may contact epascorecard@covermymeds.com.

Summary of ePA Availability

ePA availability changes often as EHR systems, payers and pharmacies work with ePA vendors to make functionality available to end users. As of the third quarter (Q3) 2015, the current availability of ePA is as follows:

  • EHR and E-Prescribing: 70% committed, 47% available, 47% live
  • Payers: 87% committed, 68% available, 68% live
  • Pharmacies: 83% committed, 82% available, 72% live
ePA: Critical For the Health Care Industry

Prior authorization (PA) was implemented years ago to provide the most appropriate and cost-effective health care services. The traditional paper-based PA process results in administrative waste and abandonment of prescriptions by patients.

  • PA costs the industry billions of dollars annually.
  • Prescribers and their staff spend more than 20 hours per week on PA requests.
  • 40% of PA requests are abandoned because of complex policies and procedures.

These challenges make it critical that the health care industry adopt a solution that creates cost and administrative efficiencies and ensures patients are not lost in the PA process.

Electronic prior authorization provides real-time information to all participants in the PA decision-making process through interconnectivity.

CoverMyMeds data demonstrates that the use of ePA significantly reduces the time spent on each PA request, up to 80%, from as many as 15 to 20 minutes to as few as 3 to 5 minutes. Turnaround time of a PA request is decreased from 3 to 5 business days to within hours in most cases, and mere moments when auto-determination is leveraged.

Early ePA Success

Although the idea of ePA has existed for years, only now is the industry experiencing the positive impact of a more efficient electronic solution.

One example is a regional health plan serving millions of members. The plan, which implemented ePA in June 2014, decreased PA reviews by 40% and increased auto-determinations by 35% as a result of ePA functionality powered by CoverMyMeds. More than half of the plan’s prescribers currently use ePA.


To create the best PA process for the industry, we recommend swift and complete ePA adoption by EHR vendors, payers and pharmacies leveraging functionality from ePA vendors outlined in the key success factors section of this report.

About ePA

Electronic prior authorization is the automated process of exchanging prior authorization requirements and connecting the various organizations participating in the process.

ePA Process 1

Today, many PA requests are completed through a manual process that involves phone calls and faxes back and forth between the pharmacy, the prescriber and the health plan. This is an inefficient process that can lead to the patient abandoning the prescription.

Electronic prior authorization automates this process by allowing the prescriber to initiate the ePA within their prescribing workflow. The most successful ePA strategies also connect the pharmacy to initiate an ePA that was missed at the point of prescribing.

The ePA process involves a four-part transaction that enables patient-specific and drug-specific PA criteria and a real-time approval process.

1 - Adapted from NCPDP SCRIPT Standard Electronic Prior Authorization Transactions Overview, August 2013

This graph illustrates prospective vs. retrospective PA requests processed by CoverMyMeds, the majority of which are started at the pharmacy.

The percentage of prospective requests includes those started by the pharmacy outside of an electronic workflow, which results in the appearance of being prospective when it was initiated by the prescriber through CoverMyMeds. Therefore, the actual percentage is likely much smaller than 29%.

2 - CoverMyMeds Data

Nationwide, physicians spend $37 billion annually interacting with health plans. Much of that cost is directly related to prior authorization and medication formulary requirements. 3

3 - Health Affairs "US Physician Practices Versus Canadians: Spending Nearly Four Times As Much Money Interacting With Payers"

Pharmacists spend an average of 5 hours per week on PA requests 2

More than half of prescribers indicate that they and their staff spend up to 20 hours per week on PA requests 2

2 - CoverMyMeds Data

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Pharmacists spend an average of 5 hours per week on PA requests 2

More than half of prescribers indicate that they and their staff spend up to 20 hours per week on PA requests 2

2 - CoverMyMeds Data

Nearly 40% of PA requests are abandoned due to complex procedures and policies and nearly 70% of patients encountering paper-based PA requests do not receive the original prescription. 4

4 - Based on a Frost & Sullivan study

Recent studies indicate 265 million claims per year are rejected, resulting in 74.4 million abandoned prescriptions. PA volume is increasing by more than 20%+ per year. 2

2 - CoverMyMeds Data
5 - Administration on Aging: The Next Four Decades, The Older Population in the United States: 2010 to 2050

There is a direct correlation between the availability of specialty and new medications and a rise in PA volume. As more specialty medications enter the market the industry will see an increase in the need for PA requests.

2 - CoverMyMeds Data

Specialty Medication Spending6

In 2014, more than $124 billion was spent on specialty medication, a $54 billion increase since 2009.

New Medication Spending6

New medication accounted for $20 billion, or 47%, of total medication spending
growth in 2014.

6 - "Specialty Drugs, Medicaid Expansion Drive Jump in Prescription Spending," Modern Healthcare, April 2015

Elderly and disabled patients who account for 52% of Medicaid spending are more likely to need medications that require prior authorization due to chronic and behavioral conditions.

It’s estimated that states will or have added more than 500,000 adults with serious behavioral health issues to their covered Medicaid population.7

Medicaid Spending

The Medicaid program can realize cost savings by leveraging ePA either through integration with Managed Medicaid Information Systems, or by requiring ePA from contracted Managed Care Organizations. Currently, only NM Medicaid, Medicaid benefits in Illinois covered by BCBSIL and Medicaid programs in Florida and North Carolina served by US Script offer ePA.2

7 - Non-Emergency Medical Transportation: A Vital Lifeline For a Healthy Community
2 - CoverMyMeds Data

ePA reduces the time spent on each PA request up to 80%, from as many as 15 to 20 minutes to as few as 3 to 5 minutes. Turnaround time of a PA request is decreased from as many as 3 to 5 business days to within hours in most cases and mere moments when auto-determination is leveraged. 2


Electronic Fax

PA Completion

15-20 Minutes

3-5 Minutes

Web Portal: 3-5 Minutes
In EHR Workflow: Seconds

PA Turnaround Time

3-5 Business Days

2-4 Business Days

Approved: Often Realtime
Denied: Less than 24 Hours

2 - CoverMyMeds Data

ePA Availability Status by EHR Vendors

The integration of ePA within EHR systems is potentially transformative to prescribers and their staff by providing a way to efficiently and effectively participate in PA within their workflow. Realizing this potential is largely dependent on supporting retrospective, prospective and all-payer capabilities. ePA integrations that incorporate these capabilities essentially eliminate the need for paper PA forms. Integrations that are missing one or more of these capabilities will still require physicians and their staff to use multiple methods for completing PA requests.

Percentage of EHR market committed to ePA and implementation status
as of Q3 2015*

*Details companies representing the majority of market share.8 This report may be updated with additional information provided by EHR vendors. Vendors can submit information to epascorecard@covermymeds.com.

16% Increase from Q1 2015
5% Increase from Q1 2015
25% Increase from Q1 2015
EHR Committed Available Live Completeness
Epic SystemsUpdated
GE Healthcare
Greenway Health
NextGen Healthcare
Practice FusionUpdated
  • KEY
  • EHR includes retrospective PA functionality
  • EHR includes prospective PA functionality
  • PA Requests completed through the EHR sytem can be submitted to any payer

8 - Software Advice - EHR Meaningful Use Market Share Industry View 2014
9 - SK&A - Physician Office Usage of Electronic Health Records Software

  • EHRs representing 70% of the market share are committed to implementing ePA, a 16% increase from Q1 2015. The largest EHRs are rapidly prioritizing ePA.
  • Between Q1 and Q3 2015, EHRs with live functionality increased significantly—from initially 22% to currently 47%.
  • Only two listed EHR or E-Prescribing vendors are live with retrospective capabilities. Several others are incorporating this functionality now and will be live soon. CoverMyMeds data indicates in 2014, 71% of PA requests were initiated at the pharmacy, whereas only 29% were initiated by a prescriber. Until more prescribers have access to and adopt a viable prospective ePA capability in their EHR system, retrospective capability will remain a key driver of ePA adoption.
ePA Availability Status by Payers

Payer integration of ePA functionality ensures all PA requests, regardless of the submission source (e.g., pharmacy system, web portal or EHR), may be reviewed and determined electronically. For payers, ePA eliminates manual entry of faxed or phoned PA requests, enables payers to receive complete information on initial submission, and eliminates determination faxes to prescribers and pharmacies.

Auto-determination functionality helps payers auto-review requests and provide real-time determinations based on preset criteria. In many cases, prescribers receive the outcome within moments of submission.

Indicating a payer is live with ePA does not mean all medications or plans—in the case of a PBM—use ePA functionality. The majority of payers activate ePA for a select number of medications or plans that they service. Transitioning a payer to ePA requires electronic incorporation of all criteria, which differs by plan and medication.

Percentage of payers committed to ePA and implementation status
as of Q3 2015*

Details companies representing the majority of market share10. This report may be updated with additional information provided by payers. Vendors can submit information to epascorecard@covermymeds.com.

20% Increase from Q1 2015
1% Increase from Q1 2015
8% Increase from Q1 2015
Payer Committed Available Live
Argus Health SystemsUpdated
CVS Health
Express Scripts
Magellan RxUpdated
Prime Therapeutics
US Script

10 - AIS’s Pharmacy Benefit Survey

  • 87% of payers representing the majority of market share are committed to implementing ePA; however, all of this growth did not occur between Q1 and Q3 2015. Rather, some of the growth is a result of updates received immediately following the March 2015 publication of this report.
  • Although the majority of committed payers have live functionality, ePA rarely extends to all the plans supported by a pharmacy benefit manager (PBM) or to all medications at the time of launch. As a result, until full rollout occurs, prescribers either need to use an ePA solution plus paper forms, or as a preferred method, electronically complete all PA requests through a web portal with universal compatibility for all plans and all medications.
  • Auto-determination functionality is likely to have the largest influence on decreasing the administrative burden for payers and increasing adoption with providers. Currently, only one ePA vendor in the market has auto-determination functionality.
ePA Availability Status by Pharmacies

The majority of PA requests are still initiated at the pharmacy, causing an administrative burden for pharmacists trying to fill prescriptions for their patients. According to CoverMyMeds, in 2014, 71% of PA requests were initiated at the pharmacy. Integrating ePA functionality into pharmacy systems gives pharmacists the ability to create a PA, auto-fill patient and medication information and electronically send it to the prescriber in one or two keystrokes. Electronic functionality significantly decreases administrative time for pharmacists, ensures more accurate data on the PA request, and prefills fields for the prescriber. The result is faster completion and submission to the payer.

Percentage of pharmacies committed to ePA and implementation status
as of Q3 2015*

*Details companies representing the majority of market share11. This report may be updated with additional information provided by pharmacy vendors. Vendors can submit information to epascorecard@covermymeds.com.

13% Increase from Q1 2015
15% Increase from Q1 2015
5% Increase from Q1 2015
Pharmacy Committed Available Live
CVS Specialty
CVS/pharmacy (Retail)
Good Neighbor Pharmacy (ABC Group)Updated
Health Mart (McKesson)Updated
Medicine Shoppe International/ LeaderNet (Cardinal Health)
Safeway/ Albertsons
Walmart (includes Sam's Club locations)

11 - Drug Store News
12 - Drug Channels

Pharmacy System Vendors

Smaller chain and independent pharmacies often purchase and use software from a third-party technology vendor rather than create their own platforms. The pharmacy system vendors integrate with ePA providers to bring ePA functionality to pharmacists at each retail location.

Details status by known pharmacy vendors.2 This report may be updated with additional information provided by pharmacy vendors. Vendors can submit information to epascorecard@covermymeds.com.

Pharmacy System Vendor Committed Available Live
AdvanceNet Health Solutions
Best Computer Systems
Key Centrix
Lagniappe Pharmacy Systems
Liberty Computer Service
McKesson (Pharmaserv)
McKesson (Pharmacy Rx)
McKesson (Enterprise)
Micro Merchant Systems
PDX (Classic & EPS)
Pioneer Rx
Prodigy Data Systems, Inc.
Speed Script
SRS Pharmacy Systems
SWI Softwriters, Inc.
VIP Computer Systems

2 - CoverMyMeds Data

  • 83% of pharmacies representing the majority of market share are committed to implementing ePA.
  • CVS/pharmacy is the last major chain not yet committed to an ePA solution that sends PA requests electronically to the prescriber.
  • Many independent pharmacies have access to ePA functionality through pharmacy systems, most of which have live, integrated ePA capabilities.
PA Legislation

Prior authorization legislation has been in consideration—and in some cases in effect— since 2013. The intent of legislation is to make the PA submission process faster and easier for providers to prevent the delay of patient treatment. Unfortunately, with no federal direction, each state is on its own path. In many cases, that path leads to legislation that simply updates how paper forms are used or provides an option for electronic submission rather than legislates a mandate for true electronic prior authorization.

PA Legislation Activity By State 13

Click any state to view legislation details.

  • = Active
  • = Pending
  • = Inactive or Dead
  • = None

ePA Legislation Activity By State 13

  • = Active
  • = Pending
  • = Inactive or Dead
  • = None

13 - CoverMyMeds Goverment Affairs team/Point-of-Care Partners ePriorAuth Navigator

  • 27 states have a law pertaining to prior authorization. Of those, nine states require the use of the nationally recognized NCPDP SCRIPT Standard when utilizing ePA.
  • Five states — Connecticut, Delaware, Missouri, New Jersey and West Virginia—have pending legislation, three of which recommend the use or consideration of the NCPDP SCRIPT Standard.
Key Success Factors

ePA vendors can help drive adoption by providing open platforms and aligning on standards for transactions. The following are key success factors for vendors, and functionality that industry participants should look for in a solution to optimize the value of an ePA process.

Plan Compatibility

ePA solutions will see greatest adoption when they are a “one-stop shop” to allow PA requests to be submitted to any plan. Early participants have found that prescriber adoption is dependent on the ePA process becoming a consistent workflow for handling all prescriptions—not just those for a few payers.

Prospective PA

Prospective PA allows the prior authorization to be completed before a claim rejection occurs in the pharmacy, thereby saving time and disruption to the patient. To enable this, the prior authorization process must be initiated in the E-Prescribing workflow. With proper implementation, and combined with real-time auto-determination from the payer, the prior authorization process begins to look more like decision support for electronic prescribing.

Retrospective PA

The majority of PA requests still occur after a claim rejection in the pharmacy. Over time, the prior authorization process will move to the point of prescribing, but only as formulary data challenges are resolved so that prescribers can adopt the prospective workflow. This process is likely to take many years. In the meantime, ePA vendors need to provide the ability to connect pharmacy-initiated PA requests into the prescriber workflow within the EHR system.


Auto-determination functionality enables payers to set criteria for PA approvals and determinations to eliminate manual review. The result is a more efficient process for payers and faster determinations for prescribers. ePA vendors who offer this functionality should allow full customization of the criteria used to make an auto-determination.

Financial Model

The market stands to save billions of dollars when all participants, especially prescribers, adopt ePA solutions at scale. Financial models that encourage ubiquity are therefore in everyone's interest, and a good way to do that is to provide ePA solutions that do not charge prescribers.

Open API

Open APIs make it easier for technology teams at EHR, payer and pharmacy systems to quickly implement ePA solutions. Documented, standards-based ePA APIs will be a key to driving adoption in the market.