Streamlining Anthem (Elevance Health) Express Scripts Integration for Pharmacy Prior Authorization

Klivira provides a robust solution for managing complex pharmacy prior authorizations, including efficient Anthem (Elevance Health) Express Scripts integration, to enhance operational efficiency for healthcare providers.

Revenue cycle directors and prior authorization coordinators face significant challenges navigating the distinct processes of various Pharmacy Benefit Managers (PBMs). While Anthem-licensed plans utilize their in-house PBM, CarelonRx, many providers also manage pharmacy benefits through other major PBMs like Express Scripts. Klivira streamlines these disparate workflows, offering a unified approach to PBM prior authorization.

Understanding Anthem's Pharmacy Benefit Management Landscape

For Anthem-licensed plans, pharmacy prior authorizations are primarily managed through CarelonRx, Elevance Health's in-house PBM. Retail PA requests route through CarelonRx's provider PA system or via established ePA partners like CoverMyMeds and Surescripts for prescriber-initiated workflows. This system is distinct from other PBMs and requires specific submission protocols.

Navigating Express Scripts Prior Authorization Workflows

Express Scripts, part of Evernorth (Cigna), operates as a separate PBM with its own set of prior authorization requirements, portals, and submission channels. Providers frequently encounter scenarios where they must manage pharmacy PAs for patients covered by both Anthem (via CarelonRx) and other payers utilizing Express Scripts. Klivira’s platform is designed to consolidate these diverse PBM PA workflows, reducing the administrative burden on your team.

Klivira's Unified Approach to PBM Prior Authorization

Klivira's automation platform centralizes the management of pharmacy prior authorizations across multiple PBMs, including both CarelonRx for Anthem-licensed plans and Express Scripts. By integrating with EMRs and various payer/PBM portals, Klivira automates data submission, tracks status, and manages documentation, regardless of the underlying PBM. This ensures consistent and efficient handling of all pharmacy PA requests.

Key Submission Channels and Policy Access for Pharmacy PA

For Anthem-licensed plans, pharmacy PA requests leverage CarelonRx's systems and ePA platforms like CoverMyMeds and Surescripts. Clinical criteria for pharmacy benefits are published by CarelonRx. For other payers utilizing Express Scripts, specific portals and criteria apply. Klivira's system is configured to navigate these varied channels, ensuring submissions meet the specific requirements of each PBM and policy.

Operational Efficiency and Turnaround Time Considerations

Pharmacy prior authorization turnaround times are influenced by state regulations, PBM service-level targets, and the efficiency of submission. While CMS-0057-F impacts Medicare Advantage and Medicaid lines, commercial plans are governed by state-specific rules. Klivira's automation helps accelerate the submission process, enabling your team to focus on clinical review and follow-up, thereby improving overall turnaround times.

Frequently asked questions

Does Anthem (Elevance Health) use Express Scripts for pharmacy benefits?

No, Anthem-licensed plans primarily utilize CarelonRx, Elevance Health's in-house Pharmacy Benefit Manager (PBM), for pharmacy prior authorizations. Express Scripts is a separate PBM (part of Evernorth/Cigna) that Klivira also integrates with for other payer plans.

How does Klivira handle pharmacy prior authorizations for Anthem-licensed plans?

Klivira integrates with CarelonRx's systems and ePA partners like CoverMyMeds and Surescripts to automate pharmacy prior authorizations for Anthem-licensed plans. Our platform streamlines data submission, status tracking, and documentation management, adhering to CarelonRx's specific requirements.

Can Klivira integrate with Express Scripts for other payers?

Yes, Klivira is designed to integrate with major PBMs, including Express Scripts, to manage pharmacy prior authorizations for patients covered by other health plans. This allows providers to centralize their PBM PA workflows across a diverse patient population.

What documentation is typically required for pharmacy PAs with Anthem (CarelonRx) and Express Scripts?

Both Anthem (CarelonRx) and Express Scripts require specific clinical documentation to support medical necessity for prescribed medications. This often includes patient demographics, diagnosis codes, prescribing provider information, medication history, and relevant lab results or clinical notes. Klivira helps organize and submit this documentation efficiently.

How does Klivira improve efficiency for managing multiple PBM prior authorizations?

Klivira provides a single, centralized platform for managing prior authorizations across various PBMs. By automating data entry, integrating with EMRs, and providing real-time status updates, Klivira significantly reduces manual effort, minimizes errors, and improves the overall speed and accuracy of the prior authorization process for both Anthem (CarelonRx) and Express Scripts.