Impacted: Prime health plan clients using CORE + RxCLAIM 

What you need to know  

Prime Therapeutics (Prime) is dedicated to reducing the friction experienced by providers and members during the Prior Authorizations (PAs) process, all while providing great value for our clients. Prime’s PA programs provide $2.7 billion in avoided costs annually across Commercial, Medicare and Medicaid pharmacy benefits.  

Our dedicated clinical teams have developed several automated PA programs, successfully reducing the need to submit a PA by 30% for drugs subject to PA. 

Overview 

You may have seen recent announcements from other pharmacy benefit managers (PBMs) about programs aimed at reducing reauthorizations. However, these announcements only pertain to reauthorizations, which only represent a small portion of overall PAs. 

Prime takes a holistic approach to enhancing value through PAs and improving experiences.  At Prime, PAs are deployed with precision, resulting in only 6% of claims requiring PA, which accounts for 58% of drug spend on the pharmacy benefit. PAs are an important tool for managing the most expensive drugs like Glucagon-like peptide 1s (GLP-1s) and can lower overall prescription drug costs by 40-50% through discounts and rebate negotiations. 

One of the key ways we are enhancing the PA process is through automation, leveraging our integrated medical and pharmacy claims data. These automation efforts have successfully reduced the need for PAs by 30% for claims subject to PA. Automation leads to approvals and helps Prime’s clinical pharmacists identify when further review is needed. 

How Prime accomplishes this 

Key programs Prime has available for clients include: 

• Smart Edits – Automated program that leverages medical data to check for an appropriate diagnosis and bypasses the need for a PA if the diagnosis is found. This saves prescribers and members time, and clients save on administrative costs of PA review. Smart Edits saved roughly $2.7 million dollars by avoiding over 50,000 PAs in Q4 of 2024 alone. Learn more about SmartEdits. 

• SmartRenew™ – Utilizes advanced client-specific algorithms to significantly reduce the need for reauthorizations of PAs once they have been initially approved. This enables members taking maintenance drugs to avoid an annual PA. SmartRenew evaluates 26% of all currently utilized authorizations for potential automatic renewal. 

• Continuation of Therapy – Enables bypass of PA for current utilizers and applies PA only to initial utilizers. Where clinically appropriate, pharmacy claims history is leveraged to help improve the member experience, reserving PA for those members who are new to therapy. 

Prime’s utilization management (UM) programs are designed to optimize drug utilization and ensure members receive clinically effective and cost-efficient medications, all while delivering exceptional experiences. Clients can elect the programs above as part of their UM strategy.  

Questions 
To learn more about Prime's efforts to improve PAs, or to elect any of the programs mentioned, please reach out to your Prime clinical account manager.