Pharmacy PA & appeals · PBMs & health plans

What happens when your competitor can scale its best clinical judgment?

Auth CR reads the full case record and prepares a complete, cited determination for each pharmacy prior authorization and appeal. It is built to apply your best reviewers’ judgment to every case and to meet your thresholds for as long as it runs.

See Auth CR in action See how it works →

Your criteria. Your clinical standards. Your decision authority.

Auth CR  /  Illustrative case
PA-2026-1041  ·  Dupilumab 300mg  ·  M.R.
Continuation appeal
Drug
Dupilumab 300mg (Dupixent)
Diagnosis
L20.0 — Atopic dermatitis
Prescriber
Dr. K. Shah, MD · Derm
Clinical note · p. 2 Dr. K. Shah · 2026-03-18

“Disease remains well controlled on current therapy. Treatment began under the prior plan. The patient has not completed the preferred-drug trial. I recommend continuation to avoid disrupting the patient’s sustained response.”

Auth CR
APPROVE Decision-Ready
✓ Coverage history Prior plan approval
✓ Clinical response Sustained control
! Preferred-drug trial Not completed
✓ Clinical judgment Support continuation
“Recommend approval of continuation. The treatment response and prescriber’s rationale support an exception to the preferred-trial requirement, which remains unmet.”
Clinical note, p. 2 · Prior authorization, p. 1
Exception rationale & draft letter ready for review
Illustrative case and policy, shown in the Auth CR case view. The same determination can appear in your UM platform.
The review window

Rules engines answer in seconds.
Denials wait for a clinician.

A request the rules can’t approve goes to a clinician, who has 72 hours to decide a Part D request or a commercial drug exception, or 24 when expedited.1 Rules in California and Medicare Part D reserve a denial for medical necessity to a physician or other qualified clinician.2 Each case in the queue competes for those hours.

  1. 45 CFR §156.122(c)(1)–(2): deadlines for a non-formulary drug exception in non-grandfathered individual and small-group plans, running from receipt of the request. They are not universal commercial PA deadlines. In Medicare Part D, 42 CFR §423.568 and §423.572 set the same 72- and 24-hour limits for coverage determinations. ↩
  2. California Health and Safety Code §1367.01(e) limits denials for reasons of medical necessity to a licensed physician or a licensed health care professional competent to evaluate the clinical issues. 42 CFR §423.566(d) requires a physician or other appropriate health care professional to review an adverse medical-necessity decision in Medicare Part D before it is issued. ↩
Clinical review

Clinical judgment in every decision.

New York · 2025 53%

In New York, independent reviewers overturned more than half of the prescription drug denials appealed to them in 2025.3

Auth CR looks for the evidence that meets each criterion and names anything missing. If the criteria aren’t met, it assesses whether the patient’s circumstances support an exception, and why, before an appeal.

  1. Checks every criterion

    Against the evidence, cited to the page.

  2. Names what’s missing

    Before any denial.

  3. Weighs an exception

    Whether the patient’s circumstances support one, and why.

What reaches your team
Approvals

Automatable under controls you define

Only in categories you authorize, at the thresholds and audit cadence you set. You can pause or narrow any category.

Denials

Prepared for a clinician to sign

The unmet criterion, the cited evidence, why no exception applies and a draft letter, so your reviewer signs with confidence.

  1. New York State Department of Financial Services, external appeal decisions, pharmacy cases decided in 2025: 1,316 of 2,476 overturned in whole or in part (53%). Precedia analysis of the public database. ↩
Placeholder · data from Ibrahim
On cases held out from learning

+[X] points

[Metric, e.g., agreement with the final decision after any appeal], across [N] cases in [drug classes].[n]

Without Auth CR’s learning
[A]%
With Auth CR’s learning
[B]%
  1. [n]. [Public case source and date of the analysis.] ↩
Where Auth CR fits

Your platform sends the case.
Auth CR returns the clinical judgment.

Auth CR connects by secure API, MCP or secure file transfer, with no change to your adjudication engine.

IntakeRequests arrive

ePA, portal and fax requests enter your PA platform.

Rules engineStructured checks

Clears what claims and form data alone can settle.

Auth CRReturns the clinical judgment

Called from your platform for each case that needs clinical review.

Your reviewersReview and sign

In your case view. Approvals in categories you authorize can close automatically.

Your PA platform calls Auth CR through a secure API, and the clinical judgment returns to the same case.

Connects through

Also available as your review queue, for teams without a review workspace.

Oversight and security

Built for audit, appeal and regulatory review.

No automated denials

Auth CR automates approvals only, within the scope you authorize. Every denial or reduction goes to a qualified clinician, with the rationale already prepared.

Automation you authorize

Automated approval runs only in the categories you approve. You can pause, narrow or roll back any scope at any time.

Complete decision record

Each record keeps the case materials as seen, the criteria version in force, the cited evidence, the reviewer’s action and the system version.

Reviewer override, any time

Your reviewers can change any recommendation. Override is a routine step in the workflow, not an exception process.

Client-level isolation

Your cases and the judgment learned from them stay in your instance and are never pooled with another client’s.

Security and privacy

Business Associate Agreement, encryption in transit and at rest, role-based access and complete audit logs. Security documentation is shared during diligence.

Getting started

Start with your hardest cases.

We work through difficult pharmacy PA and appeal cases with your team, then measure Auth CR on your own history before it touches a live case.

  1. Step 1

    Demonstration

    Difficult pharmacy PA and appeal cases, worked end to end.

  2. Step 2

    Evaluation on your history

    Historical PA and appeal records, shared under a BAA. Results are measured on cases held out from learning.

  3. Step 3

    Readout

    Findings on clinical performance, reviewer capacity and cost per case, with a recommendation on where to start.

Evaluation and shadow review are not billed.

See Auth CR in action
Contact

Request a demonstration.

We’ll walk through difficult pharmacy PA and appeal cases end to end and outline what an evaluation on your history would involve.

Or email us directly

[email protected]

See Auth CR in action

Please leave patient information out of this form.