Please note that in the chart above:

• The dotted trendline represents the % of PA processed in 4 hours or less
• The solid bar represents the % of PA processed in 24 hours or less

This performance measure is important because it allows the Pharmacy Unit to monitor that the Pharmacy Benefits Manager (PBM), Change Healthcare, is meeting the prior authorization (PA) turnaround time of 24-hours in accordance to their contract and CMS Federal requirement, Social Security Act 1927

The performance measure represents the percentage of PAs turned around with a determination in 24-hour and 4-hour time frames. This is measured from the time a PA request is received in the Call Center until a PA determination is made, and a Notice of Decision is issued.

On February 21, 2024, the Department of Vermont Health Access reported that Change Healthcare, the Pharmacy Benefit Manager which operates Vermont's Medicaid pharmacy claims system, experienced a significant cybersecurity issue which impacted data reporting. Limited data reports were unavailable from February through June, and partial for July 2024.   PAs processed in 24-hours between August through November 2024 are near or at 100.0% for each month. The 4- hour timeframe is more stringent than what is federally and contractually required and helps measure the vendor’s performance and supports DVHA’s pharmacy PA program when speaking with providers and other stakeholders.

Narrative last updated:  12/11/2024

• Change Healthcare-Provider Call Center Staff
• DVHA’s Enrolled Prescribers and Pharmacies