Automating the prior authorization process

The process of prior authorization (PA) has long been a central component of a successful formulary and utilization management strategy. Used to confirm that a prescribed treatment is clinically appropriate, prior authorization promotes better health outcomes and cost-effective care by ensuring proper use of high-cost therapies.

Despite the many benefits of PA, the process itself is complex and can lead to additional administrative burden for providers and delayed access to care for patients. That’s why we have worked to simplify prior authorization through ongoing strategic technology investments and process improvements. The result of this multi-year effort is a more seamless and expedited approach to PA that reduces administrative burden for providers and gets medications to patients sooner without compromising clinical rigor.

Reducing prior authorizations for maintenance medications

Earlier this year, Optum Rx announced the elimination of up to 25% of reauthorizations — more than 10% of overall pharmacy prior authorizations — to simplify how patients with chronic conditions receive their medications. With minimal additional value in reauthorizing a prior authorization for an effective, lifelong treatment, this initiative began with approximately 80 drugs for various chronic conditions, helping keep patients on their medications and reducing workloads for physicians and pharmacists.

Beginning July 1, 2025, Optum Rx removed reauthorization requirements on an additional 60-plus drugs. These include medications to treat seven chronic conditions including behavioral health, HIV, dry eye disease, high cholesterol and hypertension. This extends and builds upon the commitment to make prescription drugs more accessible and support better health outcomes.

With these additional medications, Optum Rx has eliminated reauthorization requirements for more than 140 chronic disease medications.

Introducing PreCheck Prior Authorization 

PreCheck Prior Authorization is the latest Optum Rx innovation to the PA process. Developed in partnership with health information network Surescripts, PreCheck Prior Authorization accelerates the path to patient therapy by automatically extracting relevant data from their electronic medical records.

By eliminating the need to manually input supporting clinical information, this industry-first innovation expedites the PA process with median turnaround times decreasing from 8.5 hours to under 30 seconds.¹

After a prescriber submits a request via EMR, PreCheck Prior Authorization assesses if the request is available for automation. If so, the system retrieves targeted clinical data from the EMR to complete questions for the PA. After analyzing the question set, PreCheck Prior Authorization sends an automatic approval if the request meets the PA criteria.

A recent pilot program of PreCheck Prior Authorization conducted with the Cleveland Clinic yielded impressive results in both the patient and provider experience. For example, the patient path to therapy was expedited with an 88% reduction in appeals and a 68% reduction in denials caused by a lack of information. There was also a decrease in physician abandonment rate of the prior authorization process, with the percentage of requests for which physicians receive a question set for additional information but never complete dropping from 31% to 25%.

“It is amazing to take what is already there in the chart to automate prior authorization without any effort from the physician, pharmacist or staff,” says Dr. Eric Boose, associate chief medical information officer, Cleveland Clinic. “I feel the promise and excitement of automation actually happening and working, and hope it grows quickly."

Currently, Optum Rx has more than 25 drugs eligible for automation through PreCheck Prior Authorization. Based on the pilot program’s results, Optum Rx and Surescripts are now expanding availability of PreCheck Prior Authorization across more health systems and additional drugs classes.