A team strategizing and reviewing different elements of a project
A team strategizing and reviewing different elements of a project

Prior Authorization Program Review and Volume Adjustment

The benefits industry needs to improve the prior authorization (PA) process and experience for patients and other stakeholders. Since 2020 the Simplify Prior Authorization initiative has been dedicated to advocating for improvements in the process, including electronic prior authorization, and providing patients, advisors, plan sponsors, and healthcare practitioners with a better understanding of the process and its challenges.

In the fourth of our six-part series on comparing the PA process in Canada vs. the U.S. we address the importance of regular prior authorization program review. 

In our first blog we provided an overview of the changing landscape of PA in the United States, specifically the 2018 American Consensus Statement on prior authorization. In our second blog we explored the role of transparency and communication in PA. Our third blog discussed the opportunity for the selective application of PA.

Regular prior authorization program review is one of the five areas of improvement identified in the Consensus Statement to improve PA.

What is regular prior authorization program review?

Very simply, payers make a regular review of their list of prior authorization drugs to identify those therapies that no longer warrant PA, or to identify new therapies where PA may be warranted. The result of this process may look different for every payer, as payers maintain autonomy over their list of PA drugs and programs to ensure drugs prescribed are appropriate, cost-effective and comply with their reimbursement criteria. Defining features of an effective program review system which the Consensus Statement in the US agreed to encourage include:

  • A review of prescriptions drugs requiring PA at least annually, with input from healthcare providers or provider organizations based on their training, expertise, and clinical experience.
  • The use of data analytics and up-to-date clinical criteria to revise PA requirements. This kind of data analytics is easier to produce if the payer is working with an electronic PA system versus a paper-based process where manual review of claims will be necessary, and time consuming.
  • Sharing changes to the lists of prescription drugs requiring PA via healthcare provider-accessible websites and at least annual communications to healthcare providers.

The Canadian Context

Prior authorization review is advantageous to payers and PA stakeholders in the U.S. and in Canada, for new and existing therapies. The rationale for review is very similar in Canada and the U.S.

When Canadian payers conduct a PA review, they can effectively use evolving clinical criteria to identify new and emerging therapies where PA may be required. As more specialty drugs work their way through the research and approval pipeline, this will continue to be a significant part of the role of review committees. According to Express Scripts Canada’s 2022 Prescription Drug Trend Report, cancer, and to a lesser extent, inflammatory conditions and multiple sclerosis have the largest numbers of new specialty drugs in late-stage clinical trials. Payers can expect to receive reimbursement submissions for at least some of them.

Regularly reviewing existing PA drugs is also an important role for payer review committees. In their review they can determine if any therapies no longer warrant PA, identify evolving clinical criteria which could change their reimbursement policies, and identify new indications and criteria.

PA stakeholders benefit from information about changes in PA lists including the addition of new drugs and changes in drug eligibility or indications. Online portals and regular communications directly to health care practitioners and patient support programs improve communication and reduce administration.

Conducting regular PA reviews and communicating the results benefits all stakeholders.

  • Efficiency and timeliness – streamlining the prior authorization list based on regular reviews ensures that only necessary restrictions remain in place, reducing administrative burdens on healthcare providers and expediting patient care.
  • Evidence-based decision-making – by incorporating data analytics and up-to-date clinical criteria, the revised prior authorization process aligns with evidence-based practices, promoting better patient care
  • Improved transparency – informing healthcare providers and patient support providers of changes in PA listings and reimbursement policies, not criteria, will reduce unnecessary administration and ineligible claim submissions.

Regular Prior Authorization Review in Canada

The regular review of PA medication list makes good business sense, and it is good for patients and other PA stakeholders. Changes should be communicated, or at least available, to stakeholders to reduce unnecessary administration.

Simplify Prior Authorization is developing best practice standards for release in 2024. Regular prior authorization review, including conducting data analytics to help identify where changes in PA may be required, will be included. Look for more from the SPA initiative, including the release of the Best Practice Standards in 2024.

If you would like to get involved in the SPA initiative and help us as we advocate for improvements in the PA process that will benefit all stakeholders, please contact us to discuss how your organization can get involved.

Look out for the next in our blog series on Canada vs U.S. prior authorization trends, the release of the new Standards, and upcoming webinars on developments in prior authorization for your industry sector.

Please reach out to SPA and contact Denise Balch at if you are interested in getting involved in the development of PA Practice Standards.

Thank you to Gold sponsors of the SPA initiative Amgen and Gilead, plus Silver sponsors AstraZeneca and Cencora/Innomar Strategies.

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