Workflow — Pharmacy Prior Authorization

Pharmacy PA without the 17 steps and 3 phone calls.

Prescription, patient history, formulary status, step-therapy requirements → match to PBM policy, identify required step-therapy documentation, calculate days-supply impact. PA submission to PBM via Surescripts CompletEPA, ePA portal, or fax. Approval / denial back to pharmacy and prescriber. Replaces PBM PA specialist labor at $4–$12 per PA at a fraction of the cost.

Take the AI Assessment Get a Per-PA ROI Model

$4–$12

Per pharmacy PA at PBM operations centers

Surescripts

Standard ePA infrastructure (CompletEPA)

60–85%

Routine pharmacy PA off the specialist desk after AI cutover

What This Replaces

The PBM Operations Center Routing Every PA Through 17 Steps

The work the PBM PA specialist does on every prescription PA — and the cost of leaving it there.

The labor

Pharmacy prior authorization today moves through PBM operations centers — typically Cognizant, Optum, Conifer Health, R1 RCM, GeBBS Healthcare Solutions, Access Healthcare, Sutherland, EXL Healthcare, AGS Health, plus PBM-owned operations at CVS Caremark, Express Scripts (Cigna), OptumRx (UnitedHealth), Humana Pharmacy Solutions, Prime Therapeutics, MedImpact. Per-pharmacy-PA cost runs $4–$12 fully loaded. PBM PA specialists work the long-tail formulary-rule and step-therapy compliance work that drives most of the 17-step / 3-phone-call frustration.

The cycle time

Standard pharmacy PA cycle runs hours-to-days from prescription submission to approval / denial, with longer cycles when step-therapy documentation is incomplete, formulary alternatives need pharmacist review, or dispensing-pharmacy-to-prescriber-office round trips ensue. Patient experience suffers — every minute a prescription waits at the pharmacy is a minute the patient is delayed from starting therapy, and every dropped PA cycle means provider abrasion that compounds over time.

The Workflow

Input · Analysis · Output

What goes into pharmacy PA, what we do to it, and what shows up in the PBM system.

Input

Prescription + patient history + formulary

Prescription with NDC and SIG
Patient medication history (claims, fill data)
PBM formulary status for the drug
Step-therapy requirements per PBM policy
Quantity-limit and days-supply restrictions
Patient diagnosis and medical context
Prior PA history for the drug / patient

Analysis

Match, document, route

PBM-policy match against the drug / diagnosis combination
Step-therapy documentation review (prior trials, failures, contraindications)
Quantity-limit / days-supply impact calculation
Formulary alternative identification
Required-attachment identification per PBM
Surescripts CompletEPA / ePA payload assembly
Confidence score per finding; exceptions to PBM specialist queue

Output

PA submission into the PBM

Surescripts CompletEPA submission
PBM ePA-portal submission (CVS, Express Scripts, OptumRx, Humana)
Fax fallback where ePA is unavailable
PBM-system update for the dispensing pharmacy
EHR / e-prescribing system status update
Approval / denial handoff to prescriber
Per-PA audit trail with policy-citation basis

Side by Side

Pharmacy PA Today vs. With Last Rev

The numbers that matter: cycle time, per-PA cost, accuracy, and patient-experience impact.

Dimension	PBM PA Specialist Processing	Last Rev Pharmacy PA
Cycle time, prescription to PA decision	Hours-to-days at PBM specialist	Minutes per PA
Per-PA unit cost	$4–$12 per PA fully loaded	Per-PA, benchmarked at 25–45% of PBM specialist unit cost
Step-therapy documentation handling	Multi-round provider chase for prior-trial / failure docs	Per-PA documentation evidence assembled from claims and records
Formulary-alternative identification	Specialist judgment, drift on uncommon scenarios	Per-drug formulary-alternative analysis with the basis cited
Surescripts CompletEPA / ePA integration	Manual ePA-portal navigation per PBM	Direct via documented Surescripts CompletEPA / PBM-ePA APIs
EHR / e-prescribing integration	Manual update to Epic / Cerner / athena e-prescribing	Direct via documented Epic / Cerner / athena APIs
Audit log per finding	Specialist notes, no per-rule lineage	Source PBM policy + step-therapy citation + claims-history evidence + confidence per element

How It Works

From Prescription Submission to PBM Decision

Five steps. Every one logged. Every one reversible if your confidence threshold isn't met.

Submission Lands

Prescription with NDC and SIG from the e-prescribing system or pharmacy — paired with patient medication history (claims, fill data), PBM formulary status, step-therapy requirements, quantity-limit / days-supply restrictions, patient diagnosis, and prior PA history for the drug / patient.

Extraction & Classification

PBM-policy match against the drug / diagnosis combination. Step-therapy documentation review (prior trials, failures, contraindications). Quantity-limit / days-supply impact calculation. Formulary-alternative identification. Required-attachment identification per PBM. Surescripts CompletEPA / ePA payload assembly.

Validation Against PBM Policy

Findings validated against the PBM's formulary and clinical policy and the plan's pharmacy-PA playbook. Anything below your confidence threshold per finding is routed to the PBM specialist review queue — final clinical / pharmacy-policy determination remains with the PBM clinical team or the plan medical director.

Push to PBM

PA submitted via Surescripts CompletEPA, PBM ePA portal (CVS, Express Scripts, OptumRx, Humana), or fax fallback. PBM-system update for the dispensing pharmacy. EHR / e-prescribing system status update. Approval / denial handoff to the prescriber.

Audit Log Persisted

Every PBM-policy match, step-therapy citation, claims-history evidence, and submission event logged with the source data, model version, prompt, and confidence score. PBM-clinical-defense-ready and yours.

Compliance & Defensibility

Built to Meet the Quality Bar Pharmacy PA Already Runs On

NCPDP and Surescripts CompletEPA conformance

NCPDP Telecommunication Standard and Surescripts CompletEPA ePA workflow respected per submission. Per-PBM ePA-API support tracked across CVS Caremark, Express Scripts, OptumRx, Humana Pharmacy Solutions, Prime Therapeutics, MedImpact.

CMS Part D and state-Medicaid posture

CMS Part D PA-timeliness rules (urgent 24 hours, standard 72 hours), state-Medicaid PA-timeliness rules, and state pharmacy-board guidance respected. Per-PA timing tracked as workflow SLAs.

No clinical-determination authority

We don't make the clinical or pharmacy-policy determination. We assemble the PBM-policy match, step-therapy documentation, and formulary-alternative analysis so the PBM clinical team or plan medical director makes the call on a richer file. Final approval / denial remains with the regulated entity.

PHI / HIPAA / HITRUST posture

Pharmacy PA data contains PHI and pharmacy claims data under HIPAA. Deployable in your VPC or our SOC 2 / HITRUST / HIPAA-aware environment. Encryption in transit and at rest; retention policies tied to your HIPAA recordkeeping rules and CMS Part D recordkeeping requirements.

Common Questions

What PBMs, Plans & Pharmacies Ask About Pharmacy PA

Those are the ePA networks where pharmacy PAs flow between providers, pharmacies, and PBMs. The competitor on this page is the PBM PA specialist labor — typically PBM-owned operations centers plus offshore support at Cognizant, Optum, Conifer Health, R1 RCM, GeBBS Healthcare Solutions, Access Healthcare, Sutherland, EXL Healthcare, AGS Health charging $4–$12 per PA. We integrate directly into the ePA network, undercut the PBM specialist labor cost, and deliver PA submissions / decisions into the PBM system.

We don't replace the PBM clinical team. PBM clinical and pharmacy-policy determinations remain with the PBM clinical team or the plan medical director. We assemble the PBM-policy match, step-therapy evidence, and formulary-alternative analysis; the clinical team makes the call on a richer file. Confidence-flagged exceptions route to the PBM specialist review queue automatically.

Our pilot success threshold is PBM-policy-match and step-therapy-evidence-assembly accuracy at parity with or above your incumbent PBM specialist process, measured on the same shadow-data sample of historical PAs. Anything below your defined confidence threshold per finding is routed to the specialist review queue — your call which queue, ours or yours.

Step-therapy documentation is assembled from the patient's claims history (prior fills, prior PA outcomes, contraindications) plus EHR documentation where available. The audit log records each step-therapy element cited so PBM clinical review resolves on a structured chain rather than a multi-round provider chase.

CMS Part D PA-timeliness rules (urgent 24 hours, standard 72 hours) are tracked per PA as workflow SLAs. State-Medicaid timeliness rules respected per state. Per-PA timing recorded in the audit log so CMS Part D audits resolve cleanly on the timeliness compliance.

Yes — through the documented integration surface each platform supports. Surescripts CompletEPA via the prescriber-portal integration; CVS Caremark, Express Scripts, OptumRx, Humana Pharmacy Solutions ePA portals via documented integration patterns where APIs exist; fax fallback where ePA is unavailable. Your IT, clinical, and pharmacy teams review and approve service accounts. We do not require platform-side custom development.

Pharmacy PA pilots typically run 4–6 weeks: 1 week of integration and per-PBM formulary / step-therapy rule mapping with the PBM clinical team, 2–3 weeks of shadow-mode running on real PAs with no PBM-side decisions, 1–2 weeks of supervised cutover on a constrained scope (one PBM, one drug class). Production rollout is staged after the pilot meets your accuracy and PBM-clinical-management sign-off.

We benchmark against your current per-PA fully-loaded cost — typically $4–$12 at PBM operations centers. Our target is 25–45% of that per-PA cost at higher accuracy and faster cycle time. Pricing structures around volume tiers and outcome SLAs (CMS Part D timeliness compliance), not hourly billable rates.

Two Ways to Start

Take the AI assessment for a structured read on pharmacy-PA feasibility. Or talk to us if you already know PBM PA backlog is the constraint on member experience and provider relations.

Self-serve · 8 minutes

Take the AI Assessment

A short structured assessment that maps your monthly pharmacy PA volume, PBM platform, and PA-specialist staffing model to AI feasibility and ROI.

Talk to a specialist

Get a Per-PA ROI Model

Send us your monthly pharmacy PA volume, your PBM platform, and your PA-specialist staffing. We'll come back with a per-PA unit-cost comparison and a 6–8 week pilot plan in 5 business days.

Other Workflows

More Healthcare Admin Workflows We Replace

The same approach, applied to the other document-heavy labor lines on your healthcare-admin budget.

Prior Authorization

Physician orders + clinical notes → InterQual / MCG match, payer-portal submission, status tracking.

Clinical Denial Appeal

Denial letters and medical records → payer-policy-cited appeal letters with evidence chronology.

HCC Coding Review

Progress notes, discharge summaries → HCC capture per MEAT criteria. Submission to CMS RAPS/EDS.

HEDIS / Stars Chart Abstraction

EMR access + measure specs → A1c, BP, screening dates abstracted per HEDIS technical specs.