Expanding Prior Authorizations; Decreasing Costs at CVS Health

Pharmacy Benefits Management (PBM) is a complex business model with moving parts, like government regulations and Medicare, and sitting on the other side of all the complexity are patients needing access to medications and care. With little room for error and lots of room for innovation, CVS Health’s PBM Product and Process Innovation team tackles each complex business challenge with enviable veracity, their tenacity in problem solving only rivaled by their respect and care for patients.

We’re sharing a behind-the-scenes look at how they approach and solve some of the toughest challenges.

“Our projects usually start with big questions,” Christie Callahan, a senior director in Strategic Process Innovation, said.

Callahan and Hillary Moore, Strategic Process Innovation Advisor at CVS Health, partnered to improve quality and efficiency of coverage determination in Medicare, which is a highly regulated segment. Prior authorizations ensure therapies are appropriate for the patients’ conditions, eliminating abuse and minimizing costs for those people who do need medications.

“We wanted to make this a more powerful tool to control costs while still serving our members in the most consistent, accurate, and timely way,” Callahan said.

The team started asking important questions: How do we make prior authorizations more efficient? How do we make our timelines even tighter for our members so they get decisions faster? And how do we make it more cost effective?

Knowing prior authorization resolution is a highly manual process–some cases get reviewed as many as seven times–Callahan and Moore knew there was opportunity to automate pieces of the process. They started by watching prior authorizations flow through the systems.

“We had to figure out what systems they were using, how processing a case worked, where people got stuck,” Callahan said.

From there, the data did the talking and propelled Callahan and Moore to create a road map for 2016 to tackle key areas, such as times pharmacists needed more information from physicians to complete prescriptions.

The process uncovered best time of day to call physicians, who should make the calls, and even the type of written communication that works best for physicians should they be unreachable by phone.

“We needed to come up with an automated solution to get information back from those prescribers and use it to efficiently process more cases for members,” Moore said.

The successful implementation of the tech solution they created reduced costs two-fold: they reduced number of times a case was reviewed while increasing the effectiveness of the review, all while staying compliant with CMS.


CVS Health is growing its PBM Process and Product teams; are you ready to solve some of health care’s toughest challenges? You can see all of our available Process and Product Innovation job opportunities on our career site.