What you need to know   

• Prime Therapeutics LLC’s (Prime) Smart Edits program drives major savings on Prior Authorization (PA) costs for clients, while improving the member and prescriber experience at the pharmacy.  

• New reporting capabilities reveal how Smart Edits assists more than 100,000 members each month in bypassing the often frustrating PA process for Glucagon-like peptide-1 (GLP-1) medications.  

• There are now eight Utilization Management (UM) programs that use Smart Edits, which are available for Commercial, Medicare and Medicaid.  

Overview  

The Smart Edits automation utilizes integrated medical data provided by clients with our pharmacy claims data in RxCLAIM. When a member fills a prescription for a GLP-1 drug, the system logic automatically checks for an appropriate diagnosis. If a diagnosis is found, the claim is paid right at the pharmacy counter, bypassing PA and saving the member time.  If no approved diagnosis is detected, the claim will not be paid, and PA will be required. 

Smart Edits is an election clients can add to their clinical programs at no additional charge, making the savings it offers clients even more significant. 

Why it matters   

While PA is an important part of UM programs, Smart Edits helps avoid unnecessary PAs and the administrative cost of manual reviews. Clients also avoid paying claims for off-label use of GLP-1 medications.  

Smart Edits works behind the scenes as members check out at the pharmacy, so patients with Type 2 diabetes skip the headache of the PA process and get the medicine they need seamlessly. 

Smart edits success by the numbers for GLP-1s 

In the fourth quarter of 2024: 

• 466,285 claims were paid via Smart Edits 

• 420,753 members were assisted by Smart Edits 

• About $2.7 million saved from over 50,000 avoided PAs 

“We are proud of the work Prime continues to do to improve the PA process for clients, members and prescribers. Our new reporting shows just how impactful Smart edits can be, and we continue to work to expand the program’s offerings to include more drugs.  We encourage all clients to utilize the program to improve member experience and take advantage of savings,” said David Lassen, vice president, clinical pharmacy services. 

Next steps  
To learn more about UM programs that utilize Smart Edits and add it to your clinical programs, please reach out to your Prime clinical account manager.