Automating Prior Authorizations for GLP-1 drugs

Impact: Commercial and Medicaid

Prime/Magellan Rx’s efforts to make the prior authorization (PA) process smoother for members and prescribers, while also reducing costs for our clients, are making a difference. The influx in off-label usage of GLP-1 drugs for weight loss has resulted in high clinical review volumes over the last year.  

In Q2 of 2023, Prime/Magellan Rx began implementing automated clinical edits at the point of sale (POS) to reduce member and prescriber abrasion and the administrative costs of those PAs.  

How it Works 

The POS automation utilizes integrated medical data provided by clients with our pharmacy claims data in RxClaim. When a member goes to fill a prescription for a GLP-1 drug, the system logic automatically checks for a type 2 diabetes diagnosis. If there is a diagnosis, the claim is paid right at the pharmacy counter, avoiding a PA and saving the member time. 

If there is no type 2 diabetes diagnosis detected, the claim will not be paid and PA will be required. This saves our clients money in two ways: 

• Saves on the administrative cost of a manual PA review  
• Avoids paying claims for off-label use of GLP-1 drugs 

This is all done behind the scenes as the patient checks out at the pharmacy. Type 2 diabetes patients skip the headache of the PA process and get the medicine they need.  

Success over the first month 

The first month of the program was a success for members and clients alike. The numbers after one month live with six of our health plan clients are impressive: 

• 33,000 PAs avoided  
• $1.5M saved for our clients 

The program continues to expand, with three additional Utilization Management (UM) programs offered in Q4 of 2023 and more programs to come.  

Prime/Magellan Rx’s commitment to improving the PA process for members, clients and prescribers has come a long way in the last year. Check out other initiatives including Smart Renew and Therapeutic Alternative Capabilities. 

Clinical edits at the POS for GLP-1 drugs can be elected as part of your UM program for all Commercial and Medicaid clients. A project is slotted in 2024 to expand this program to Medicare. To learn more, contact your Prime Clinical Program Manager.