How digital solutions saved more than $5m for a healthcare client’s specialty pharmacy group


A large healthcare client faced two challenges:

  • Cost-effectively manage a large volume of pre-certification requests for its specialty pharmacy business
  • Simplify its complex and expensive distribution, administration, and patient management environments

With those challenges in mind, we identified several benchmarks to measure the success of our management program:

  • Mitigate long turnaround times
  • Accommodate both commercial and Medicare plans
  • Adhere to contractual restrictions
  • Abide by state regulations
  • Improve both member and provider experiences

Human Ingenuity

Our multi-pronged approach delivered a management program with a strong focus on digital solutions:

  • Digitally sorted, prioritized and routed faxed prior authorization forms to the appropriate destinations
  • Automated the process for specialty medication pre-certification
  • Created a standardized review system with nurse associates to determine if a patient request meets existing clinical guidelines or if it should be routed to medical directors for further assessment
  • Streamlined provider phone requests for specialty drugs to identify pre-certification forms with complete information and forms requiring outreach calls for additional information


For five consecutive years, the healthcare organization’s specialty pre-certification and pharmacy group realized an annual savings of more than $5 million dollars. Both commercial and Medicare plans contributed to the savings.