Reducing the Administrative Burden of Prior Authorizations at the Pharmacy
By Anna Peterson Sanders, PharmD, BCGP, pharmacist at Network Health
4/28/2025
The words “prior authorization” (PA) often elicit a groan from members and providers alike. We get it. It can slow down care for patients, add paperwork for providers and often leads to extra work when the information isn’t complete or arrives too late. Network Health is taking steps to streamline this process and reduce burden while speeding up the process of members getting their medications.
You may be wondering why prior authorizations (PAs) exist if all they do is cause headaches. The purpose is to ensure medications are being prescribed appropriately, in line with their approved uses or expert guidelines. PAs also give the opportunity to ensure members have tried the lower cost alternatives. Many of the PAs in place are on high-cost drugs, often running beyond $100,000 for a one-year supply. If we can help inform members and providers on the lower cost and efficacious formulary alternatives, we can help keep more money in their pocket.
Additionally, PAs may be in place for safety reasons. For example, certain medications used for the elderly can lead to increased side effects and risks such as confusion and falls. Our Medicare formulary contains some of these safety PAs, ensuring a provider has assessed the risk versus benefit of prescribing the medication as well as suggesting formulary alternatives that minimize risk of these side effects.
Network Health is working to make the PA process easier by cutting down on the need for manual approvals. We’ve partnered with Express Scripts to launch a system that uses real-time information to approve prescriptions automatically. It pulls data from past medical and pharmacy claims to decide instantly if a prescription meets coverage and safety requirements. If the system finds all the information it needs and meets criteria, it processes instantaneously, and the member can get their prescription without waiting on their provider to complete a PA. If the system doesn’t find all the information, it will go down the usual pathway of requiring the provider to do a PA. It’s important to note that the automated reviews never lead to a denial, only approval.
As an example of our efforts, in August 2024, we started testing this system with glucagon-like peptide (GLP-1) inhibitors, medications commonly used for the treatment of type 2 diabetes. Since then, the need for PA on these drugs has dropped by 62 percent. Thanks to that success, we are expanding the system to automate calcitonin gene-related peptide (CGRP) inhibitors, used as migraine prevention drugs, in mid-2025.
This change means doctors and clinic staff spend less time dealing with paperwork and more time caring for patients. It removes unnecessary steps in the approval process and speeds up access to medications without skipping important checks on safety and coverage.
We’re working closely with Froedtert and other health care partners to make sure the new system fits smoothly into their current workflows. These partnerships help us spot any issues early and make sure the changes don’t disrupt care.
We’re also keeping an eye on whether this process reduces the number of prescription appeals, which can lead to further delay in access. When approvals happen faster and with better information, fewer people need to appeal a denial.
Looking ahead, we plan to connect this system with Epic, the electronic medical records system, by 2026. This will make the process even more efficient by expanding beyond just medical and pharmacy claim data. Automation will be in place to pull information from chart notes to answer other items such as questions related to laboratory values, pathology reports and radiology findings.
By making prescription approvals simpler, Network Health is helping providers save time, cut costs and get patients the care they need more quickly.
