Case Study

Leading PBM: $100 Million in Savings with Automated Approvals

Real-Time Intelligence and Automated Business Processes

The PBM needed a solution to meet two key objectives. First, it needed to automate routine prior authorization approvals, freeing clinicians to focus on disease management and member relationships. Second, the PBM needed to increase the efficiency and productivity of its technician staff by eliminating paper-based, manual lookups. With Pega, the PBM has added real-time intelligence to streamline calls and authorizations. For PA automation, rules for each prescription drug are established just once and Pega dynamically modifies and invokes the rules in real time, eliminating unnecessary manual intervention. For pending PAs requiring intervention, Pega automatically routes relevant information to the appropriate staff. “Pega can read all of our different systems, aggregate the information with rules, and resolve a case with minimal time and cost. That’s what makes it such a great system,” noted the Call Center Manager.

Faster Authorizations at Significantly Lower Cost

Using the Pega solution, the number of pended authorizations decreased and technician productivity skyrocketed, resulting in a 55 percent drop in the cost per case compared to the previous year. Technician training was cut from 12 to less than eight weeks. With the Pega-powered PA process, the PBM has simplified benefit determination, integrated inbound faxes to automate routing and streamlined its Web portal so that clients can now get real-time status updates. The company discovered how quickly new solutions can be implemented with Pega. Recent pricing changes to its formulary impacted thousands of guideline procedures, which would have taken months to change in the old PA system. Using Pega, the change took only a couple of weeks, and the modification to the existing rules ensured that the over 500,000 members affected get their prescriptions without a hitch. In addition, the Pega solution automatically notified all members of the change. Now, calls that took eight minutes are resolved in less than five, and the intent-led process allows untrained staff to handle overflow.


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