Accelerating Oral Oncology PA with Surescripts Integration

Klivira's oncology Surescripts integration empowers cancer care providers to automate and accelerate prior authorization for critical oral oncolytics, reducing administrative burden and improving patient access.

The complex landscape of oncology prior authorization is further complicated by the split between medical and pharmacy benefits. High-cost oral chemotherapy and targeted therapies, vital for many cancer regimens, fall under the pharmacy benefit and require efficient electronic prior authorization (ePA) workflows. Klivira directly addresses this challenge.

The Unique Demands of Oncology Prior Authorization

Oncology presents one of healthcare's most intricate PA environments, characterized by high-cost biologics, frequent regimen changes, and a critical need for rapid treatment initiation. While IV therapies are typically managed via medical benefit PA, oral oncolytics — equally vital — require a distinct pharmacy benefit ePA pathway, often through platforms like Surescripts.

Critical Oral Oncolytics Requiring Surescripts ePA

Oral chemotherapy agents (e.g., capecitabine, temozolomide)
Oral targeted therapies (e.g., Gleevec, Tagrisso, Verzenio)
Oral hormone therapies for breast and prostate cancer
Supportive care medications administered orally that fall under pharmacy benefit

Harnessing Surescripts for Pharmacy Benefit Automation in Oncology

Surescripts plays a pivotal role in standardizing and expediting electronic prior authorizations for pharmacy benefit drugs. For oncology practices, integrating with Surescripts via the NCPDP SCRIPT standard means a more efficient process for securing approvals for oral oncolytics, moving away from manual faxes and phone calls to a streamlined digital exchange.

Key Documentation for Oral Oncology ePA via Surescripts

Confirmed diagnosis, including pathology report and tumor staging (AJCC TNM where applicable)
Relevant molecular markers (e.g., EGFR, ALK, PD-L1, HER2, BRCA) guiding treatment selection
Documentation of prior-line treatments, response duration, and rationale for current regimen
Performance status (ECOG or Karnofsky) and relevant comorbidities
NCCN Clinical Practice Guidelines and Compendium citations for medical necessity

Klivira's Solution for Oncology Surescripts Integration

Klivira's platform provides a robust oncology Surescripts integration, connecting directly with your EMR to extract necessary clinical data. Our NCCN-compendium-aware logic automatically structures and submits the comprehensive documentation required for oral oncolytic PAs, ensuring accuracy and expediting payer review, ultimately reducing critical delays in cancer care.

Beyond Surescripts: A Comprehensive Oncology PA Approach

While Surescripts integration optimizes the pharmacy benefit pathway, Klivira's platform offers a holistic solution for oncology PA. We manage the full spectrum of PA events, from J-code chemotherapy and biologic infusions (medical benefit) to advanced imaging and radiation oncology, ensuring all PA requirements are met across the entire patient journey.

Frequently asked questions

How does Surescripts integration specifically benefit oncology practices?

Surescripts integration primarily benefits oncology practices by automating prior authorizations for oral oncolytics and other pharmacy benefit drugs. This accelerates the approval process, reduces manual administrative tasks, and helps ensure patients can start critical treatments faster, directly impacting time-to-treatment intervals.

What types of oncology medications are processed via Surescripts?

Surescripts is used for medications that fall under the pharmacy benefit. In oncology, this primarily includes high-cost oral chemotherapy agents, oral targeted therapies like Gleevec or Tagrisso, and oral hormone therapies. It does not typically handle IV-administered drugs which are processed under the medical benefit.

Does Klivira's Surescripts integration handle all oncology prior authorizations?

Klivira's Surescripts integration specifically streamlines prior authorizations for pharmacy benefit drugs, such as oral oncolytics. For medical benefit PAs, covering IV chemotherapy, biologics, radiation, and advanced imaging, Klivira utilizes other direct payer integrations and X12 278 transactions to ensure comprehensive coverage across all PA types in oncology.

What EMR data is typically used for Surescripts ePA in oncology?

For oncology ePA via Surescripts, Klivira extracts crucial EMR data including confirmed diagnosis, tumor staging, relevant molecular marker results, prior treatment history and response, and performance status. This data is critical for demonstrating medical necessity against NCCN guidelines and payer policies for oral oncolytics.

How does Klivira ensure compliance with NCCN guidelines for oral oncolytics submitted via Surescripts?

Klivira incorporates NCCN Clinical Practice Guidelines and Compendium awareness into its policy logic. When submitting an ePA for an oral oncolytic via Surescripts, the platform automatically identifies and structures the necessary documentation based on the specific regimen and tumor type, helping to ensure submissions align with recognized medical necessity criteria.