1. Healthcare

January 28, 2015
The Honorable John C. Watkins
Chair
Senate Commerce and Labor Committee
General Assembly Building, Room 331
Capitol Square
Richmond, VA 23219
RE: Senate Bill 1262 – Prior Authorization
Dear Senator Watkins:
The Academy of Managed Care Pharmacy (AMCP) is writing to express our opposition to Senate Bill
1262. However, we would support a substitute bill to permit electronic submission of prior authorization
requests as referenced in Section 38.2-3407.15:2 B2. AMCP recognizes prior authorization programs,
developed by health plans in conjunction with pharmacists, physicians, and other health care practitioners,
as an essential tool used to ensure that patients receive medications that are safe and effective for their
medical condition and that prescription drug benefits are administered as designed by the payer.
AMCP is a national professional association of pharmacists and other health care practitioners who serve
society by the application of sound medication management principles and strategies to improve health care
for all. The Academy’s nearly 7,000 members, with 169 living and practicing in Virginia, develop and
provide a diversified range of clinical, educational and business management services and strategies on
behalf of the more than 200 million Americans covered by a managed care pharmacy benefit.
The provision to allow ePA referenced in Section 38.2-3407.15:2 B 2 will enhance electronic prescribing
and prior authorization workflows and ensure a more complete information exchange between the
prescriber, patient and payer to help identify and approve appropriate medications. Electronic transactions
provide for a bi-direction, real-time exchange of information between payers and prescribers. Such
transactions also support the appeal and cancellation of ePA information exchanges.
Prior authorization procedures and requirements for coverage are based on clinical evidence and
therapeutic need. Administration of a prior authorization process must consider the desired outcome for the
patient, the design of the drug benefit, the value to the plan sponsor, and all statutory and regulatory
requirements. Therefore, AMCP cannot support the remaining provisions in Section 38.2-3407.15:2.
Those provisions seek to impose government mandated provisions on private payer prior authorization
programs.
For example, specific provisions are required if a patient is receiving mental health benefits and
if a patient has changed from one carrier to another carrier. Health plans need the flexibility to
treat each patient based on that patient’s medical records (therapeutic need) and the clinical
evidence pertinent to that patient. A “one size fits all” prior authorization program is less
favorable to the patient.
Legislation that creates more paper forms when the overall health care system is moving towards
the use of electronic formats is not helpful to your constituents. The electronic format will allow
providers and health plans to make decisions quicker and more efficiently. When a provider
submits a paper form, the carrier has to input that information into an electronic system, which is
time consuming. The time tables in the proposed legislation for a response from the carrier (24
hours and 48 hours) are more realistic in an electronic based environment. Those timetables are
not realistic in a paper form environment.
We recognize that the prior authorization requirement is sometimes a contentious issue;
however, there must be a balance between the prescriber’s desire to request approval for a
specific medication and the ability of the health plan to evaluate that request because approvals
of inappropriate therapies could compromise patient safety and unnecessarily increase costs. For
the stated reasons, we oppose Senate Bill 1262. However, if you propose a bill in the nature of a
substitute that would allow the use of ePA, AMCP would support that bill. The use of ePA will
be of great benefit to your constituents – patients, prescribers and payers. If you have any
questions, you may contact AMCP’s local advocacy leader, Jason Richardson at (804) 405-5074
or [email protected], or AMCP Vice President of Government Affairs, Lauren Fuller,
at (703) 683-8416 or [email protected].
Sincerely,
Edith A. Rosato, R.Ph., IOM
Chief Executive Officer
cc: Members of the Senate Commerce and Labor Committee
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