.png)
FOR PBMs AND HEALTH PLANS
Licensed pharmacist prior-authorization and utilization-review capacity, delivered as a managed service.
RPhAlly supplies credentialed, state-licensed pharmacists for prior authorization and utilization review — working in your platform, against your criteria, with scheduling, QA, and reporting handled by us. The clean approvals are automating; the exception queue still needs qualified people you can defend on audit. That is the work we staff.
RESULTS FROM A LIVE PROGRAM
Measured results from a live medical-benefit UM program.
Large academic health system, April–September 2026. One pharmacist, about 65 hours a month — under half an FTE.
$197K
Confirmed cost avoidance
In six months, priced at WAC — a floor, not an estimate.
$500
Avoided per pharmacist hour
395 review hours, April through September.
1,669
Authorizations decided
Two quarters, up 14% quarter over quarter.
92–97%
True approval rate
Approvals ÷ (approvals + denials).
01
Caught step-therapy denials upstream
When payers tightened criteria on IV iron and viscosupplementation mid-quarter, true denials rose 165% — and the pharmacist caught them before they reached the plan or the patient. Highest single confirmed case: $26,500.
02
Resolved cases with low member abrasion
Wrong-code and wrong-diagnosis requests were dismissed with a message to the prescriber and resubmitted correctly — one resubmission approved the same day. Biosimilar routing where the reference product would have been denied.
03
Kept turnaround inside payer SLAs
The program runs 99% on-time, with an average decision time of about five hours, while handling more complex denial work.
04
Reported in a form leadership can act on
Monthly volume, approval rate, denials by class and payer, confirmed avoidance by case, and a payer watch-list — the same reporting your accreditor and your CFO both want.
Results are from a client engagement, April–September 2026. Cost avoidance counts only denials confirmed by chart review (the patient did not receive the drug by another path), priced at WAC; where reimbursement could be sampled, WAC understated it by about 30%. The Q3 figure includes partially validated September cases subject to final chart review.
THREE WAYS TO ENGAGE
Capacity, a program, or a clinical lead — scoped to your queue.
Each engagement is scoped individually. Most plans start with the bench and a measured pilot.
01
Reviewer bench
Overflow and surge capacity. A named panel of licensed pharmacists reviews inside your system under your UM program, with RPhAlly owning scheduling, inter-rater reliability, and turnaround reporting. Typically working your queue within weeks.
02
Delegated UM program
RPhAlly runs a UM function end to end for a line of business or drug category: program description, policies, criteria application, turnaround tracking, appeals routing, and reporting, with physician review arranged where the state or your program requires it.
03
Fractional clinical lead
A senior pharmacist as your part-time UM clinical director: criteria writing, P&T support, inter-rater reliability program, appeals QA, and audit readiness.
Add-ons on any model: appeals and peer-to-peer preparation; after-hours, weekend, and specialty-category coverage.
HOW WE WORK WITH A PLAN OR PBM
Built to pass your audit, not just clear your queue.
Six commitments that hold on every engagement, from the first case.
01
Your platform, your criteria
Pharmacists review inside your PA system under your UM program, with minimum-necessary PHI access under a BAA. No PHI leaves your platform.
02
Complete determinations, start to finish
Licensed pharmacists make the full coverage decision — approvals and denials — against your criteria, with documentation built for appeal and audit. Reviewer authority follows each state's utilization review law and your UM program; where a physician reviewer is required for an adverse determination, we build that routing into the workflow with you.
03
Capacity scaled to your queue
Credentialed, state-licensed pharmacists onboarded as volume requires: primary-source verification, monthly OIG and SAM screening, criteria training, and inter-rater sign-off before independent work.
04
Fee for service, always
Hourly, per case, or retainer. Never a share of savings, revenue, or referrals.
05
Start measured
A 60–90 day pilot at hourly or capped-retainer pricing to measure time per case in your environment, then convert to per-case pricing on real data.
06
Reporting your accreditor expects
Monthly turnaround and QA reporting in the format your accreditor expects — volume, approval rate, denials by class and payer, and confirmed avoidance by case.
THE HIRING MATH
Why contract the capacity instead of hiring the seat.
A growing number of states now bar automated adverse determinations or require a licensed clinician to make them, and federal prior-authorization turnaround rules tightened in 2026. The clean approvals are automating; the exception queue still needs qualified people you can defend on audit.
OPTION A
Hire a full-time UM pharmacist
• Salary, benefits, and payroll paid whether the queue is full or not
• Three to six months to recruit and credential before the first case
• No flex for surges or payer policy swings
• One person, one set of licenses, one point of failure for coverage
OPTION B
Contract the capacity from RPhAlly
• Pay for review hours or cases, not for a seat
• Working your queue in weeks, not quarters; scale up or down with volume
• The program above avoided $197K in six months on about 65 hours a month — under half an FTE
• QA, inter-rater checks, licensure files, and monthly reporting included
WHO YOU'LL WORK WITH
Managed-care and regulatory experience on the same bench.
Pharmacist-in-Charge experience at a national mail-order operation and a URAC-accredited opioid stewardship program, alongside two former presidents of the California State Board of Pharmacy.
START WITH A CONVERSATION
Tell us where your queue sits.
The states, the lines of business, the volume, and whose criteria. We will come back with a pilot shape and a reporting template — no packages, no percentage-of-savings pricing.
Prefer email? Write to info@rphally.com.
Reviewer authority follows each state's utilization review law and the client's UM program. Engagements are scoped individually. RPhAlly is a consulting organization and does not provide legal advice.