Aetna Streamlines Prior Authorization with Integrated Prescription and Procedure Review

Aetna has introduced an integrated prior authorization process that combines pharmacy prescriptions and medical procedures into a single clinical review. This change eliminates the previous need for providers to submit separate prior authorizations for related medical procedures and medications, streamlining approvals and reducing administrative burden. For example, procedures such as in vitro fertilization (IVF) and associated pharmaceuticals now undergo one unified review, with medication approvals following automatically once the procedure is authorized. As part of CVS Health, Aetna is leveraging its clinical, pharmaceutical, and technological capabilities to enhance payer-provider interactions and simplify healthcare navigation. The company views prior authorizations as essential tools for managing care quality and insurance coverage while seeking to reduce friction points within the system. This initiative aligns with Aetna's broader strategy launched earlier in the year to improve healthcare system efficiency. In addition to the integrated prior authorization bundles, Aetna recently expanded its offerings by introducing musculoskeletal care bundles that cover X-rays, knee replacement surgeries, medications for pain management, inpatient admissions, infection control, and durable medical equipment. This builds on earlier authorizations targeting cancer care, signaling a trend towards comprehensive condition-specific bundles that streamline the approval process for complex treatments. Aetna’s Clinical Collaboration program further supports patient transitions from hospital care to home or skilled nursing facilities, aiming to reduce 30-day readmission rates and shorten hospital stays among Medicare Advantage members. Currently implemented in 17 hospitals, this initiative is expected to expand across both Medicare and commercial markets. Supporting these operational changes is CVS Health’s significant digital investment, totaling $20 billion, which integrates artificial intelligence and digitally enabled solutions into member services. The Aetna Health app now features conversational AI, with plans to expand generative AI capabilities throughout the digital experience by early 2026. These advancements promise to enhance user engagement and facilitate more personalized healthcare management.