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Automated workflows help a U.S. PBM deliver faster, trusted outcomes
A leading U.S. pharmacy benefits manager (PBM) grappled with a manual, email-based process for Physician Clinical Reviews (PCR). The legacy workflow slowed case turnaround, created compliance risks, and burdened both internal teams and physicians. Virtusa reimagined the process with a Pega Constellation-based, cloud-hosted app that automated matching, codified decision rules, and improved compliance tracking. This enabled faster reviews, improved physician experience, and provided a scalable platform for future growth.
Time is often the difference between relief and prolonged suffering for patients awaiting approval for critical therapies. However, the PCR process at this PBM was completely manual. Reviewers still used emails, chat messages, and spreadsheets, relying on their judgment to match physicians, track timelines, and remember critical clinical rules from memory.
The consequences were serious. Review turnaround times often stretched beyond mandated service-level agreements, exposing the organization to compliance penalties. Physicians grew frustrated with the cumbersome process of scheduling and responding to review requests.
Most importantly, patients at the center of this process faced unnecessary delays in receiving therapies deemed medically necessary.
In a competitive market, these inefficiencies threatened patient trust, provider loyalty, and overall market reputation.
The PBM partnered with Virtusa to modernize manual processes and unlock a faster, more reliable service for patients.
Rather than modernizing incrementally, Virtusa and the PBM embraced a bold approach of building the organization’s first cloud-native Pega application from the ground up. The new system was designed on Pega’s Constellation architecture, providing a modern user experience, real-time data flow, and scalable infrastructure.
The heart of the solution was a rules-based automation engine that replaced ad-hoc human decision-making with structured workflows. Requests were automatically routed to the right physicians and matched intelligently based on specialty, availability, and location. This reduced scheduling friction while ensuring the most qualified experts completed reviews. Integrations with upstream and downstream systems, built on Kafka, JSON, and APIs, enabled real-time data exchange, improving visibility and compliance tracking.
The delivery model was equally important, and Virtusa applied an agile, iterative approach, engaging business users early and often in show-and-tell sessions. When delivery challenges pushed the project into red status mid-way, strong governance across Virtusa, Pega, and client leadership helped reset priorities, accelerate decision-making, and steer the initiative back on course.
The impact of the new system was immediate and meaningful. Turnaround times for clinical reviews dropped significantly, ensuring patients gained access to critical therapies faster.
By embedding decision rules directly into the platform, Virtusa reduced manual errors and achieved consistent, auditable outcomes that satisfied both regulatory bodies and client-specific SLA requirements.
Key outcomes included:
The PBM improved its internal processes and strengthened its ability to deliver timely, compliant, patient-centered care. However, the success of this initiative went beyond immediate efficiencies.
The PBM chose Virtusa as its transformation partner because of its deep domain expertise in healthcare and proven ability to deliver engineering-first solutions tailored to complex clinical workflows. Virtusa’s mastery of Pega Constellation and cloud-native builds, combined with strong governance and agile delivery practices, positioned it as the right partner to reimagine the clinical review process.
The new platform developed by Virtusa is designed for scalability and continuous evolution. As medical review volumes grow and healthcare regulations shift, the PBM now has a flexible foundation to expand automation, integrate advanced analytics, and adopt AI-driven capabilities. This future-ready architecture ensures the solution will not only sustain current improvements but also open new opportunities for efficiency, accuracy, and better patient outcomes in the years to come.
administrative tasks eliminated
improved operational capacity
faster peer-to-peer reviews
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