Automating GLP-1 prior authorizations at scale.

GLP-1 prior authorizations for Medi-Cal MAP are clinically dense. Each case requires evaluation against MACE, MASH, OSA, and EPSDT criteria, labeled-indication logic, aid-code eligibility, and ICD-10 validation — followed by documentation via a defensible fax template. Adjudicated carefully, each case represents substantial clinical work; at volume, the workflow becomes a throughput constraint.

If criteria logic, aid-code lookup, and documentation templates were consolidated into a single purpose-built interface — rather than distributed across PDFs, spreadsheets, and internal references — cases could be routed more efficiently without compromising clinical rigor.

• 8 clinical criteria modules — structured Approve / Defer / Deny paths for MACE, MASH, OSA, EPSDT, and labeled indications, with LOA calculation and CTI code assignment built in.
• 365-entry Medi-Cal aid-code database — scope, share-of-cost, and pharmacy-benefit eligibility mapped for every code I encounter, plus guidance for 12+ reject-code types.
• ICD-10 validation engine — labeled-diagnosis matching per drug with five-category indication classification. No more tab-hopping to confirm a code.
• EPSDT workflow — CDC BMI-for-age percentile logic for ages 2–20, automatic under-21 detection, and custom PA end-date calculations.
• Dynamic fax template generator — module-aware documentation so the rationale always matches the decision.
• 130-point PA Quality Audit rubric across 5 domains (verification, data input, reject analysis, clinical criteria, pending items) — used for self-audit and training.

~3.5 minutes saved per case. ~40% reduction in end-to-end workflow time. More cases adjudicated, fewer documentation gaps, and a clinical-reasoning trail that’s easy to audit.

Prior-authorization workflow is a meaningful bottleneck in managed-care pharmacy. Each minute recovered is a member who receives medication sooner and clinical time redirected to decisions that require pharmacist expertise.