PreCheck MyScript®: Easing the prior authorization process for physicians and patients

Tim Sullivan, Pharm. D., director of pharmacy market solutions for UnitedHealthcare, describes a real-time benefit check solution that’s integrated into the electronic medical record (EMR) to give prescribers patient-specific information and simplify the prior authorization process at the point of care. For more information, please visit UHCprovider.com/pcms.

Medical Economics 

Dr. Tim Sullivan, Director of Pharmacy Market Solutions with UnitedHealthcare, thank you so much for joining us today.

Tim Sullivan

Good to be here.

Medical Economics 

Prior authorizations are a pain point for physicians and other health care professionals. What's being done at UnitedHealthcare to improve the prescribing workflow?

Tim Sullivan

Great question. And obviously, you know, we're always at that inflection point, we need to make sure that we're doing everything we can to deliver benefits that meet the clinical needs of the members we serve, that do so in a manner that also drives an amount of responsible spending and affordability for the clients that ultimately are purchasing our benefits. And really, at the crux of a lot of that is the management techniques that we put in place to do that. And programs like prior authorization, you the intent is we need a little bit more information from a doctor to make sure that we have a comfort level that it's the right drug for the member. And those programs are really effective, but what we've done in recent years is we build things like PreCheck MyScript, which ultimately the best way to think of it is us swimming as far upstream as we can in the prescribing process. This is embedded right in a doctor's electronic medical record (EMR) system, to make sure that when they go and prescribe a medication, that it's going to tell them if that is even covered for that member. And if, for example, it requires a prior authorization, we can let that provider actually execute that authorization and it give us everything we need to know right then and there at the point of prescribing. So what what we're basically doing is we're setting up a situation where that member gets access to a drug that works for them, we've met our comfort level, we've met that prior authorization comfort level, and it doesn't result in a stop or an inflection point at the pharmacy where the member can't get that medication, and now the prescriber's got to do something different. So that's one really good instance of us sort of inserting ourselves a little bit into the process to make it a better experience for our providers and members, and still bring that same level of clinical and and cost value.

Medical Economics 

Can you go a bit more in depth on PreCheck MyScript and how it works and how it's integrated with the EMR system?

Tim Sullivan

So I think folks have a rough idea of what an EMR is, it's really the point of everything that a provider does for their patients. One of the functions of all modern EMRs is what's called electronic prescribing. Gone are the days where a doctor writes on a pad, hands it to you, and you physically have to bring that to a pharmacy; really the vast majority of prescriptions are electronically prescribed. And they almost all come out of an EMR, literally the doctor's typing in the name of the drug and prescribing it for their for their patient, our member, while they are there. Precheck MyScript is a module within that doctor's EMR. What it actually does is runs a live test claim against that member's exact benefit setup. And it kicks back to the provider in real time. How is that drug covered for that member, for that patient of theirs? And ultimately it gives them all the basics. Is it covered? iIf it's not covered, what are the covered alternatives? If it is covered, are there any lower cost alternatives? Or, if it requires a prior authorization, for example, it'll allow the doctor to execute on that right then in there. So the EMR doctors are in that, that's not something new, they're playing in that all day long. What PreCheck is is it's just a module built in the EMR that allows them to execute on that real-time benefit check at the moment that they're prescribing a drug.

Medical Economics 

Can you give a real world example of a patient visit and how this would work in practice?

Tim Sullivan

I'll give a couple examples: a really commonly prescribed medication, cholesterol lowering drugs, a class of drugs called statins. Millions of Americans use those drugs. They're relatively interchangeable from a clinical standpoint, but the cost difference can vary widely from one to the next or from brand to generic. So, in PreCheck, if a doctor goes to prescribe, for example, for UnitedHealthcare member, they've prescribed a drug Crestor, it's likely going to give them lower cost options that we cover instead, generic options. And so that's a real straightforward example. I would say most providers recognize that dynamic today. Another example would be medications like drugs to treat ADHD. We often require prior authorization on those medications, they are in fact scheduled stimulant medications that we would have some moderate concern around potential abuse for those medications that would extend outside of their original reason for treatment. So, often on those medications, we require prior authorization. And it's really we just need to confirm that, in fact, that members a has ADHD is a good candidate to use that drug. So that would be a simple instance where it might ping them that prior authorization and give them the chance to just give us the confirmation we need right then in there at the point of prescribing. The best way to think of this as giving us a chance to nudge a provider into making the decision that's right based on that member's coverage. And the way I always say is: it's almost certain that the prescriber wrote for the right drug, but there are hundreds of formularies. Right, every carrier has their own formulary, even within a single carrier, they might have many formularies. So we're not saying to the doctor that that was the wrong choice, we're just saying in that drug class, here's the one that's lower cost for that member's benefit design or lower tiered. So it's really nudging them in a direction to really ensure that they're they're making formulary adherent decisions that fit within that members exact benefit setup.

Medical Economics 

Can you talk about the financial benefits for patients from PreCheck MyScript?

Tim Sullivan

There's a benefit every time a provider puts in a medication where there's a lower tiered opportunity. So I think we all understand tiering as it pertains to a pharmacy benefit: tier one is going to be your lowest cost share medications, tier two and three, and sometimes there's four-tier benefits design. So as you step up, that member cost share goes higher. So there's often instances where a tier three medication might have a lower cost drug than in tier one, a generic or another drug in the same class that does the same thing. So that tier three drug is covered. But let's just say it has a member copay of $75. Tier one copays are commonly $10. So you're looking at a situation where if a prescriber picks a tier three drug at a $75 copay, and there's a tier one opportunity available at $10, that's simple math of $65 a month that a member could save simply by that that choice being made at the point of prescribing that is more formulary inherent. I think our data tells us that, on average, when providers do make a switch of that nature that we're looking at as much as $225 in real time savings for a member. And it can be much higher than that if it's a medication that member might be taking every month into perpetuity. So it really gives a chance to drive what can be fairly significant savings for the member.

Medical Economics 

Just a quick follow up. If there's financial benefits to the patient, then it might boost medication adherence as well. Is there any any data on that?

Tim Sullivan

I would say it's it's relatively early, but we're looking in the low single digits up to low low double digits in terms of adherence. So when we track PreCheck MyScript activity, and we isolate the instances where in fact a provider did make a choice at the point of prescribing to a lower tiered alternative, we are seeing increased adherence there. And there's really what amounts to a mountain of clinical evidence and research that's been done on that space, that cost does play a role into adherence on medications. But it is a relative truth that if you can drive affordability in terms of out-of-pocket member dollars, that it does make meaningful impact on them continuing to use that drug as prescribed, and our early data is starting to really bear that out for us.

Medical Economics 

So when physician is actually using PreCheck MyScript, and they see that cost information in there, where does that data actually come from? Is that real time data?

Tim Sullivan

Yeah, it's real time. It's based on that exact members benefit experience. The pharmacy side of healthcare is extremely complicated. So, you know, if you're a member, you might be in your deductible phase — that's going to have a different cost experience. You might be post deductible, is it copay or coinsurance? And there's a lot of other programs that we could have in play that could in fact, impact what's the true member costs of that drug. And all of that is defined within your benefit setup. And the only way to really know what that is, is to actually run a live test claim against your benefits — just like what would happen if you're at the pharmacy, and they were processing your prescription. That's what PreCheck MyScript does, it actually runs a live claim to see exactly what that drug looks like from a coverage standpoint and cost standpoint, based on that member's exact benefit setup. So what is returning to the prescriber, to the doctor, when they use PreCheck within their EMR is exactly what that member would experience if they went to the pharmacy at that moment, and tried to fill that drug. So it truly is a real-time check against that member's benefit setup.

Medical Economics 

For physicians who may be interested in checking out PreCheck MyScript and seeing it in action, what EMR systems is this available in?

Tim Sullivan

At this point, we're in pretty much all of the major EMR systems, you know, whether they be more of the cloud based systems DrFirst or more of your traditional EMR systems, like an Epic type system. So at this point, we've got fairly robust coverage. I think in earnest, if you look at all of the Unitedhealthcare's providers, we're at a little over 70% of them now have access in their EMR to PreCheck MyScript. And that's only going up. I'll often get asked, well, why are we at 100, Tim? This program started in 2018, so we were at 0% of our providers with it only a couple years ago. So we've seen a tremendous growth, that hockey stick type curve, where we're starting to get to a point where we've got really phenomenal saturation. And that's and that's simply because we're more or less engaged with all of the big players in the EMR space, and we continue to fill those gaps.

Medical Economics 

Last question: is there anything else that's important for physicians to know about PreCheck MyScript that we haven't discussed?

Tim Sullivan

PreCheck MyScript, that's kind of the way we face out on it. But in terms of a prescriber, they might know it more by the industry term of real-time benefit check. And the reason I say that is because when they're actually in their EMR, it's not called PreCheck MyScript there. Each EMR might call it a slightly different thing. But that little module within your EMR when you go to prescribe a drug and it's kicking you information on coverage, know that that's what that is, and and we are making sure that those EMRs that we are connected with them, that we're trying to continue to grow our footprint. But one of the biggest things I always tell providers is, is start to get comfortable with where that is. If you've got questions, work with your contacts at those at those EMR vendors and get more comfortable with it. Because, ultimately, what we're trying to give you is information that really saves you time, that gives an opportunity for members to have lower costs, prevents those stops at the pharmacy because the drug you pick, which is probably clinically the right drug, just isn't the exact right one for that members benefit set. It's all trying to smooth out the experience better experience for our providers, for our members, with an opportunity to ultimately lower cost. There's a lot of benefit there, but just make sure you're comfortable with it, know how to use it, and ask questions if you don't.