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Patient Support Programs (PSPs) may secure alternate funding from pharmaceutical manufacturers when there are reimbursement gaps, but that is just one role. PSP providers like McKesson, Innomar, BioScript, Sentrex and Bayshore are paid to help patients through the prior authorization claims process required for some medications and secure reimbursement. Their counterparts who are publicly funded and typically work in hospital settings are Drug Access Navigators (DANs) or Reimbursement Specialists. Both PSPs and DANs are critical to expediting patient access to medications in a very complex reimbursement environment.

Why is the Prior Authorization Claims Environment Complex?

There are many reasons. Here are a few:

• In Canada, 20 group insurance carriers adjudicate close to 1 in 10 claims¹ through a prior authorization (PA) process for specialty drugs. They either manage the process themselves, or it is contracted out to a third party like one of the pharmacy benefit managers (PBMs). Together, they are referred to as payers.
• Payers typically have their own unique claim form for each indication (disease or condition) for every drug. How to find the right claim form and an explanation of the claims process are not always clear.
• Once the right claim form for a patient’s condition is secured from their payer, the form can be completed. Currently PA claims can be completed on paper and some online. For submission to the payer, the completed form and any medical records must be printed and mailed or faxed. There is no online submission process for claim forms that are completed online.

With so many carriers, close to 500 specialty drugs, and hundreds of claim forms, figuring out the claims process and following through with making a claim can feel overwhelming for patients. PSPs and DANs make a huge difference in the patient’s reimbursement journey, and also ease physician’s workload.

How Does a Patient Support Program Work?

Patients are usually referred to a PSP or DAN by their physician for assistance. They offer tailored resources to overcome the financial, logistical and education barriers for patients’ needs including:

• Reimbursement Navigation: PSPs and DANs assist patients with the prior/special authorization claims process for their medication, including understanding coverage limits and appeals if a claim is denied. They also often explore funding from both private and public sources. Some also provide a short supply of free product, called bridging, from the pharmaceutical manufacturer while patients wait for their insurance plan or public approval.
• Financial Assistance: Many PSPs and DANs coordinate copay assistance, help with deductibles, or free medications for qualifying patients. These services reduce the financial burden that specialty medications or therapies can place on a patient.
• Medication Adherence Support: PSPs provide education on proper use of medications and therapies, medication reminders, and other tools to help patients stay on track with their treatment regimens.
• Psychosocial Support: Living with a medical condition can be emotionally taxing. Some PSP programs offer counselling, peer support, or community resources to help patients and their families cope.
• Injection / Infusions: For drugs given by injection or infusion into a vein, PSPs often provide coordination or education to have these drugs administered quickly and easily. Often these services are provided free of charge, with the drug manufacturer paying for the drug administration.

In the face of an often-cumbersome prior authorization process, PSPs and DANs stand out as advocates for patients, bridging the gap between healthcare providers, insurers, and patients.

For a more detailed definition of a PSP, visit the Simplify Prior Authorization glossary.

More About Prior Authorization

For PSPs, DANs and anyone else looking to enhance their understanding of stakeholders in the prior authorization process and the group benefits industry, the Simplify Prior Authorization website offers a wealth of tools and insights. The site was developed to provide targeted information on PA to anyone, even patients, plan sponsors and group benefit advisors. There is also a resource page that includes links to sites where insurer claim forms can be found, and information about provincial coverage, as well as much, much more.

Is There a Way to Simplify Prior Authorization?

Simplifying the PA process is critical to its viability in the future. The existing process is almost all manual and this takes more time than is necessary for everyone involved.

There is a strong rationale for change and significant benefits to implementing communication and administration/workflow efficiencies, including electronic prior authorization (ePA). PSPs, patients and physicians are frustrated with the slow, manual paper-based, mail/fax claims process. Payers have been experiencing added pressure to their claims administration human resources and expenses because of the GLP-1 class of medications, whose indications have now expanded. Payers must either pass on the additional PA claims adjudication expenses to clients or it will have a direct impact on their bottom line.

The technology exists to ensure that all prior authorization claim forms can be accessed, completed and submitted online. However, payers have not risen to the challenge and adopted ePA. On the bright side GreenShield Canada and OkRx, a technology solutions provider, are working together to bring the first integrated electronic prior authorization system to patients.

Simplify Prior Authorization is primarily an advocacy and education campaign. However, the Prior Authorization Framework and Accreditation (PAFA) program goes one step further. PAFA is the new Canadian membership and accreditation non-profit that recognizes payers who commit to its guiding principles and meet its administration and ePA framework. For information on membership, associate membership, and accreditation, contact Denise Balch info@simplifypriorauth.ca, denisebalch@priorauthframework.ca or 905 220 4260.