Prime Therapeutics reimagines prior authorization to deliver member care faster

The Business Issue

As one of the largest privately held pharmacy benefit managers in the United States, Prime Therapeutics (Prime) helps more than 25 million members access the therapies they need. Prime plays a critical role in determining medical necessity and coverage decisions, whether reviewing specialty medications, oncology treatments, or other high-cost therapies.

These reviews sit at a pivotal point in the prior authorization journey. Delays can slow access to medically necessary therapies, while inconsistent decisions can create friction for providers and patients.

For Prime, the effectiveness of this process became increasingly important. Getting these reviews right – fast, consistent, and defensible – directly shapes both the provider experience and how quickly members get the therapies they need.

For years, Prime managed Physician Clinical Reviews (PRC) through a largely manual process. Clinical reviewers communicated through emails, Teams messages, and individual conversations. Knowledge about physician specialties, availability, scheduling requirements, and review rules often existed in employees' heads rather than in a system. And more than just an inefficiency, every manual handoff was another chance for delay or inconsistency in a decision a patient was waiting on.

"We went from a manual process where information was in people's heads to really building out not just a process, but a rules-based engine," explained Amy Browne, Vice President of IT Innovation at Prime Therapeutics.

What made the challenge particularly significant was that PCR was not an isolated workflow. It was a critical component of the broader prior authorization process, where efficiency, consistency, and turnaround times have a direct impact on providers, members, and regulatory obligations. Prime's leaders understood that continuing to rely on manual coordination would make it increasingly difficult to scale while maintaining the level of service and clinical rigor they expected.

Like many healthcare organizations, Prime also saw the ripple effects: faster, more transparent, and more consistent clinical reviews ease friction for providers and patients, and even smooth downstream work like appeals and exception handling. PCR is one stage of the process, but it’s one of the most consequential.

As demand continued to grow, the organization needed a way to improve operational efficiency while maintaining clinical quality, physician satisfaction, and compliance with client and regulatory requirements.

Prime established three clear objectives for the initiative:

• Improve operational efficiency
• Maintain patient safety and clinically sound decisions
• Remain compliant with client turnaround-time expectations and regulatory requirements

The Solution

Rather than simply digitizing existing steps, Prime used the opportunity to reimagine how physician clinical reviews should work.

The team brought together business leaders, physicians, product owners, technology teams, and implementation partners to design a future-state process from the ground up. Their goal was not to replicate the old process inside a new application. It was to create a more intelligent operating model.

One of the biggest breakthroughs came when the team shifted conversations away from documenting current procedures and toward defining desired outcomes.

Prime leaders said helping users "step away from what you do today and try and figure out what you want it to look like tomorrow" became a critical part of the journey.

The resulting solution centralized physician review workflows while introducing automation and decision rules that previously depended on tribal knowledge.

The new application automated physician profile management, peer-to-peer review coordination, physician matching, case routing, notifications, tracking, and review management. A key capability was automatically matching cases to physicians based on specialty, availability, and business rules rather than relying on manual coordination.

The organization also adopted a cloud-first architecture and intentionally built a reusable foundation capable of supporting future business needs rather than a single use case. Prime used Pega Cloud® – a rules-based architecture – and a scalable design intended to support future expansion into additional areas of the business. With Pega as the foundation, Prime could reimagine the process at design time and then run it predictably. Governed workflows and built-in rules let the team move fast without sacrificing the clinical rigor, consistency, and auditability the work demanded.

Equally important was how Prime approached implementation.

Project leaders accelerated feedback cycles by involving users earlier than originally planned. Frequent demonstrations and iterative reviews replaced a traditional end-of-project testing model. The early feedback loops helped the team discover issues sooner, refine requirements, and build a solution that better reflected real-world user needs.

Strong governance also played an important role. Prime, Virtusa, and Pega worked together through multiple layers of governance, helping remove obstacles, address challenges, and maintain accountability throughout the project.

The Results

Prime began the initiative with three objectives: maintain patient safety and clinical decision quality, improve operational efficiency, and strengthen compliance. By the program's conclusion, the organization had achieved measurable improvements across all three areas.

• Operational efficiency and speed: By automating key review activities and eliminating manual handoffs, Prime reduced the time required to complete physician-to-physician reviews by 20%, shortening average review times from 99 minutes to 83 minutes. Operational capacity increased by 16%, enabling the organization to process more reviews while maintaining clinical rigor. Administrative processes improved as well, with internal batch denial review processing becoming 80% faster and external batch denial review processing improving by 65%. Administrative tasks associated with the process were eliminated entirely.
• Governance, transparency, and compliance: The benefits extended beyond speed. The new system provided transparency into review timelines and turnaround times, helping Prime better monitor service commitments and regulatory obligations. By replacing ad hoc coordination with a rules-based process, the organization reduced opportunities for manual error while improving consistency, auditability, and confidence that reviews were being completed according to established requirements.
• Scalability: Most importantly, Prime now has a scalable foundation capable of supporting future growth rather than a workflow constrained by manual processes and institutional knowledge. The organization is better positioned to expand capabilities, support additional business needs, and continue improving how critical clinical decisions are managed across the healthcare journey.

For Prime, the Physician Clinical Review initiative is not viewed as a finished project but as a foundation.

The organization is exploring opportunities to extend the platform into additional business areas, including broader pharmacy benefit management processes. Leaders are also evaluating how cloud technologies, process mining, voice technologies, and AI-enabled capabilities can further improve healthcare operations.

The lesson from the project is clear: Modernization is most effective when organizations resist the temptation to merely automate existing work.

Instead, they must challenge assumptions, engage users early, and design around the outcomes they want to achieve.

As Prime discovered, meaningful transformation begins not by asking how to digitize today's process, but by asking what tomorrow's process should look like. And for the more than 25 million members Prime serves, a faster, more consistent review means faster access to the therapies they’re counting on.

Watch Prime's in-depth journey here.