(14) Impact of a Medical Claims Automated Glucagon Like Peptide-1 Drugs Prior Authorization Program

Background: : Medication prior authorization (PA) generally requires prescribers to submit verifying information, e.g., diagnosis, to the health plan or pharmacy benefit manager (PBM) for coverage determination. Glucagon like peptide-1 products (GLP-1s) are frequently not covered for weight loss, however, are covered for diabetes mellitus (DM). A GLP-1 PA requiring DM diagnosis is common. PBMs integrated with their health plan have access to medical claims data and can automate the PA DM diagnosis verification, allowing the GLP-1 PA authorization to occur at the pharmacy point of sale. However, little is known of the impact of this program on PA reviews.

Objective: : To measure the impact of the PBM using health plan medical claims diagnosis to automate the GLP-1 PA process through assessing the percentage of all DM FDA approved GLP-1s PA reviews that were automatically approved.

Methods: : Prime Therapeutics’ integrated pharmacy and medical claims data from 15.3 million commercially insured members were used to identify members with a DM GLP-1 pharmacy claim PA review between October 2024 and December 2024 (4Q2025). When a pharmacy submits a DM GLP-1 prescription claim for a member newly initiating DM GLP-1 therapy a PA is required to verify the DM diagnosis. The automated PA process checks the member’s medical claims for a DM diagnosis. If a DM diagnosis is found, the PA is authorized and claim is paid right at the pharmacy counter, bypassing traditional PA review. If no DM diagnosis is detected, the claim will not be paid, and standard PA process is required. All 4Q2025 DM GLP-1 claims that were approved via the automated review process were identified and divided by all DM GLP-1 PA reviews to determine the percent approved via the automated review process.

Results: : Among 15.3 million commercially insured members, in the 4Q2024, 466,683 (45.3%) DM GLP-1 claims were adjudicated via the automated process out of a total of 1,029,152 DM GLP-1 PA claims. These 466,683 automated DM GLP-1 PA claims assisted 200,021 members, or 1 in 77 of all 15.3 million members.

Conclusions: : Automated PA, utilizing the medical claims diagnosis information, allowed for 45.3% of DM GLP-1 PA claims to adjudicate at point of sale, benefiting one in 77 of all insured members. While PA is an important part of PBM utilization management programs, automated PA helps avoid unnecessary reviews and manual review administrative costs. Clients also avoid paying claims for off-label use of GLP-1 medications. Automated DM GLP-1 PAs work to simplify the PA process, helping members get the medicine they need seamlessly.

Sponsorship:: Prime Therapeutics