Automated Prior Authorization Speeds Approval of GLP-1 Therapies | AMCP Nexus 2025

Using technology to automate the prior authorization process for GLP-1 drugs to treat people with diabetes simplifies the process and helps members get the medicine they need seamlessly, finds a researcher from Prime Therapeutics, which was presented as a poster at the Academy of Managed Care Pharmacy (AMCP) Nexus. The meeting was held at the Gaylord National Resort and Convention Center in National Harbor, Maryland.

In Prime’s analysis, more than 6 out of 10 members with diabetes who had a prescription for a GLP-1 medication had the prior authorization approved at the pharmacy counter. This, Prime found, helps avoid unnecessary reviews and manual-review administrative costs.

“While prior authorization is an important part of PBM utilization management programs, automated PA helps avoid unnecessary reviews and manual-review administrative costs,” Patrick Gleason, Pharm.D., assistant vice president of health outcomes, Prime Therapeutics, told Managed Healthcare Executive by email. “Clients also avoid paying claims for off-label use of GLP-1 medications. Automated diabetes GLP-1 PAs work to simplify the PA process, helping members and providers.”

In 2024, 26.5% of adults with diagnosed diabetes used GLP-1 injectables to lower blood sugar or lose weight, according to data from the CDC’s National Center for Health Statistics.

The impact of the GLP-1 therapies on patients’ weight has led to increased demand for therapies such as semaglutide (Ozempic for diabetes and Wegovy for obesity) and tirzepatide (Mounjaro for diabetes and Zepbound for obesity). The high costs of these therapies, however, have raised concerns among payers. Many payers require prior authorization to ensure that patients meet the criteria in the products’ labels.

Prior to Prime’s analysis, little had been known of the impact of an automated prior authorization for GLP-1 drugs specifically to treat patients with diabetes. Researchers at Prime wanted to understand the impact of the pharmacy benefits manager (PBM) having medical claims data integrated with diagnostic information had on automating GLP-1 drug PA approvals for patients with diabetes.

Researchers at Prime analyzed pharmacy claims and enrollment data from January 2023 to July 2025 across 19 commercial health plans. They used integrated pharmacy and medical data from 15.3 million members whose plans used an automated review for GLP-1 therapies to treat diabetes.

The automated prior authorization process checks the member’s medical claims for a diabetes diagnosis. If a diabetes diagnosis is found and all other criteria are met, the prior authorization is approved and the claim is paid right at the pharmacy counter, bypassing traditional review. If no diabetes diagnosis is detected among the member’s medical claims, the claim will not be paid, and a standard prior authorization process is required.

Researchers assessed the members with a diabetes GLP-1 claim that was approved via the automated review process compared with members with a paid diabetes GLP-1 claim through either the standard review process or automated review to determine the percentage of members with claims via the automated review process.

They also determined the per member per month (PMPM) cost for prescriptions for GLP-1 drugs for diabetes by dividing the monthly total claims paid amount by the membership in the month.

They found that the automated diabetes GLP-1 prior authorization proportion of all diabetes GLP-1 claims grew by 17.5 percentage points, or 39.6%, from October 2024 to July 2025.

In the most recent month of analysis, July 2025, among 15.3 million commercially insured lives with the automated diabetes GLP-1 active, two-thirds of all diabetes GLP-1 claims processed in the month were done through the automated process, 215,178 (61.7%) of 348,624. The automated diabetes GLP-1 prior authorizations assisted 215,178 (1.4%) of 15.3 million members, or 1 in 71 of all our members.

Gleason said Prime is looking to expand its automated prior authorization process, leveraging the medical integration with its Blue Plan partners.