Logic Behind In-Scope Drugs
This content in this topic describes how Question Set Automation evaluates and answers ePA questions for drugs that fall within scope.
Important: Question Set Automation compares the patient’s clinical data to the standardized drug criteria to determine whether the prior authorization (PA) automation process should continue.
For example, when evaluating Enbrel, the system checks whether the medication is being used in combination with a targeted synthetic oral small‑molecule drug. Because this combination is not indicated, the presence of such a drug stops PA automation. If no targeted synthetic oral small‑molecule drugs are found, Question Set Automation proceeds and will only submit a PA request if the patient’s clinical evidence meets the drug’s criteria.
Question Set Automation stops the PA automation process and returns the request to the health system’s standard PA workflow when:
- Clinical evidence is required, but none is found.
Example: No documented diagnosis of diabetes.
- No clinical evidence should be present, but evidence is found.
Example: A contraindication that disqualifies the patient.