Automated Prior Authorization


As drug regimens increase in complexity, cost, and risk, the implementation of smarter PA systems is essential. Fully-automated prior authorization solutions provide an efficient, independent, and objective means of ensuring appropriate utilization, cost containment, and deterrence of fraud, waste, and abuse. Successful automated PA solutions also help plans recapture staff hours previously spent on manual review and allow reduced administrative burden on provider staff.


RxPert® is a fully-automated prior authorization adjudication system which receives medication coverage determination requests. The request is evaluated using all available pharmacy, medical, and eligibility data, and returned in a real-time, secure NCPDP P4 transaction, with no human interaction. In fact, response times average less than 500 milliseconds.


Because the system is fully-automated, every determination is made objectively, based solely on the available data.


RxPert adjudicated more than 9 million requests in 2016 with average turnaround time of .48 seconds.

Ongoing Review

Each potential dispensing of a medication is reviewed to ensure the patient continues to meet criteria.

Cost Savings

Proven return on investment studies illustrate millions of dollars saved annually without risking patient health

Clinical Expertise

RxPert uses clinical expertise to make superior coverage decisions by leveraging secure, scalable technology. RxPert has refined the prior authorization process, reducing costs, improving consistency, and allowing prescribers, dispensers, and agencies to reduce hours previously spent on manual or partially-automated prior authorization processes and the burdens that accompany them. By utilizing automated PA processes, our clients are controlling appropriate therapy with auditable, consistent and objective rules.

What you get:

  • An automated, manageable way to consistently and efficiently apply PA criteria and ensure clinical appropriateness
  • Rapid processing that allows for complex and extensive edits which would be cost prohibitive to complete manually
  • Consecutive processing of all criteria so that providers receive notification of all criteria steps which have failed in a single transmission, rather than one at a time
  • Minimized impact on providers, pharmacies, and patients because edits are evaluated based on accessible data, and not on person-to-person interaction
  • Proven success in seamlessly integrating with claims systems and third party call centers across the country