Challenge
As specialty medications become increasingly important in treating complex and chronic conditions, providers and specialty pharmacists face growing administrative complexity in determining how therapies are covered and routed.
Each treatment decision requires an evaluation of plan design, coverage policies, site of care requirements, and drug-specific criteria, often across multiple systems and stakeholders. In response, a more seamless experience was created to help patients access the treatment they need faster, while making it easier for providers to navigate the care journey.
Solution
Cigna Healthcare worked with Autonomize to deploy Intelligent Benefit Routing, a solution designed to help providers and specialty pharmacists determine the correct benefit routing more quickly and consistently. The AI-enabled technology compiles relevant benefit, coverage, and policy information and applies predefined routing criteria, enabling routing recommendations to be delivered 50 times faster while supporting accuracy and consistency. Human reviewers remain accountable for oversight and complex case handling. The solution operates within established governance and oversight processes designed to support transparency, accountability, and responsible use of AI.
Results
Reduced administrative effort associated with benefit routing.
Improved consistency in applying routing criteria across cases.
Increased transparency through documented routing rationale and auditability.
Enabled specialty pharmacy teams to begin the fulfillment process sooner with earlier routing direction.
Created additional capacity for teams to focus on exceptions and complex cases.
Value
By reducing administrative complexity and providing earlier routing clarity, the solution helps create a more predictable experience across a patient’s care journey.
The value reaches everyone involved in the care journey. Providers receive faster, more predictable answers on coverage and spend less time chasing routing questions. Specialty pharmacists receive earlier direction, allowing them to begin fulfillment steps and patient outreach sooner.
“This work demonstrates how AI can help reduce administrative complexity in health care while maintaining the transparency, governance, and human oversight required in a highly regulated environment. By helping teams navigate routine routing decisions more efficiently, we can create a more predictable experience for providers and specialty pharmacists while also empowering our experts to focus on the most complex cases.”
— DP Koka, EVP, Global Chief Information Officer, The Cigna Group
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