Reducing unnecessary prior authorizations provides a better benefit experience for members, their employers, and providers. To explore how CarelonRx is streamlining prescription approvals, we asked Jeff White, Staff VP, Clinical Pharmacy Services at CarelonRx, for his insights.
Our approach to Rx prior authorization (PA)
Prior authorization in pharmacy remains an important clinical safeguard, helping ensure medication use is aligned with evidence for safe and effective treatment that supports better health for our members. At CarelonRx, we’re optimizing the member experience by simplifying the PA process and reducing unnecessary PAs. Here, Staff VP Jeff White shares highlights of our approach and the measurable results.
Q: What is the purpose of prior authorization for prescription drugs?
A: Overall, PA helps ensure evidence-based use of drugs and therapies with the goal of improving health of our members. We are focused on simplifying care, ensuring our members can access care quickly, closing care gaps, and verifying that the therapies our members receive are safe and clinically validated. Pharmacy prior authorization is a critical safeguard in achieving this goal. That’s why the goal isn’t “no PA,” it’s streamlining the process to provide even faster approvals for appropriate therapy, especially in high-impact categories.
Q: What is the scope of the prior authorization process at CarelonRx, and what are the results of continual enhancements around PA?
A: Only a small minority of the prescriptions we manage actually require prior authorization, and we’ve continued to remove PAs that may no longer be necessary. We increased our focus on simplifying the experience for members and providers while continuing to prevent inappropriate prescribing and waste. We’re enhancing our processes without compromising clinical rigor, so the right medications can start sooner — and our 2025 results show meaningful progress.
A big driver of those results has been expansion of Proactive Prior Authorization, which delivers near real-time approval in select drug classes and clinical scenarios when the member’s integrated medical and pharmacy information shows criteria are met.
“By leaning into the most effective tools and approaches, we’ve enabled a clinically informed, tech-supported, proactive PA practice that requires fewer steps and less time than ever before.
Q: Please break down for us the main ways CarelonRx is reducing PAs.
A: We are reducing PAs in four main ways:
1. Proactively approving through Proactive Prior Authorization.
These are typically cases where approval criteria are driven by confirmed diagnoses — such as cancer, diabetes, or ADHD — and we can verify that information in real time using integrated medical and pharmacy data. We can approve immediately without requiring additional steps from the provider.
2. Eliminating PAs found to be no longer necessary as part of continual process refinements.
We continuously analyze medical guidelines, peer-reviewed research, and patient outcomes to remove PAs that are no longer clinically necessary.
3. Proactively extending PAs that are nearing expiration.
When ongoing therapy remains appropriate, we extend prescription approvals before they expire, removing the need for providers to resubmit requests. This helps avoid treatment interruptions and supports medication adherence so members can stay on track with their health.
4. Making tools and support easily accessible for care providers.
We streamline the process by promoting electronic prior authorization (ePA), enabling timely submissions, and providing clear clinical guidance — helping providers complete requests efficiently and reducing back-and-forth.
Conclusion: Reducing prior authorizations through approaches like Proactive PA and ePA helps CarelonRx maintain clinical rigor while making the pharmacy benefit work better for everyone involved. For employers, fewer manual PAs can translate into a smoother overall benefit experience, while also helping manage drug trend and spend by reinforcing use of evidence-based therapies. For members, streamlined approvals mean faster access to needed medications and less administrative back-and-forth. For providers, fewer resubmissions along with faster decisions reduce potential administrative burden and free up more time for patient care.
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