Prime Therapeutics automated physician clinical review routing for prior authorization on Pega.

Manual physician reviews created bottlenecks and inconsistent prior authorization decisions, with key information held in emails and individual knowledge. The pharmacy benefit manager built a rules-based workflow on Pega Platform and Pega Cloud for matching, routing and coordination. The page reports 20% faster peer-to-peer review turnaround (99 to 83 minutes), 80% faster internal denial reviews and a 16% rise in capacity.

Pega is a low-code workflow and decisioning platform, used by payers, pharmacy benefit managers and pharma for case management and next-best-action

This sits in the Ship stage of the AI use-case lifecycle: Named examples from the vendors pharma teams use to get an AI system live inside a real, regulated production workflow — validation, CRM, safety and clinical systems of record.