Did you know that changing group insurance carriers can result in loss of access to specialty medications for plan members? This can happen even when a plan member’s claim has been approved through prior authorization with the old carrier, usually for twelve months, and there are no changes to the drug plan formulary with the new carrier.
Without an industry grandfathering agreement for prior authorization claims, the onus is on plan advisors to coordinate the continuation of coverage of these claims through the transition to a new carrier. If advisors fail to do so, then plan members may find themselves without coverage for their specialty drug when the change takes place.
The application and prior authorization process for specialty drug claim can take weeks or sometimes months, involving coordination between physicians, patient support programs, and plan members. When a plan member must make a new prior authorization claim to the new carrier, the application and processing time may mean access to their medication is interrupted. Since specialty drugs are typically used to treat serious medical conditions, any interruption in access to their medication can have serious medical consequences and impact their mental health and finances. A new prior authorization application, which is paper based, is also time consuming for physicians, patient support programs and insurance companies.
Since 2020 the Simplify Prior Authorization (SPA) initiative has been calling for a grandfathering provision to eliminate unnecessary coverage gaps on change of carrier. Plan members on specialty drugs should have a seamless transition of coverage from one insurance carrier to another. They should not have to worry about the potential of losing access to their specialty drug just because their employer has changed insurers.
An industry grandfathering provision for specialty claims approved for prior authorization would resolve the potential for loss of coverage on change in carrier. Until then it is up to advisors to ensure that plan members don’t lose coverage. Advisors can also consider:
Prior authorization and insurance carrier gaps can present real challenges, but with advocacy, better communication between insurers, and the adoption of the PAFA Program, these challenges can be minimized. Plan members deserve access to the care they need and should not lose access to care during an insurance transition.
For more information on SPA, PAFA, and what you can do as an advisor to help create positive change for prior authorization, you can contact Denise Balch at denisebalch@connexhc.com or call 905 220 4260.
In this blog, we focus on the important role of Drug Review Committees in maintaining a responsive and sustainable PA process through a regular review of existing medications as well as reviewing new medications that may be subject to prior authorization.
The interest in prior authorization is growing, which is driving more interest in reforming current practices and policies to become more efficient and drive down administration costs and reduce the time-consuming claims process.
Navigate the prior authorization (PA) process in Canada can be time consuming and confusing. Inefficiencies in the system create real challenges for all stakeholders—physicians, pharmacists, insurers, advisors, and most importantly, patients.
The Simplify Prior Authorization initiative is an advocate for education about prior authorization (PA) and improvement in current prior authorization practices and processes. If your organization is interested in finding out more, getting involved, or in sponsorship of this important initiative, please contact us via the link below.