Blog

Managing prior authorization (PA) lists and criteria for specialty drugs is critical to ensuring patients have access to the specialty and some high-volume medications they need. Payer drug evaluation committees take on this important responsibility, not an easy task in today’s ever-changing environment.

Today there are hundreds of drugs that are subject to prior authorization in Canada. This places a heavy burden on payers responsible for reviewing new drugs, establishing reimbursement criteria and managing existing PA lists. It’s also challenging for manufacturers, physicians, patient support programs, patients and plan sponsors.

To ease the burden on drug reviews, Canadian private payers, including insurers and third-party administrators, often take into consideration PA reviews by pharmacy benefit managers (PBMs) like Express Scripts and TELUS. Payers often rely on PBMs to administer some or all of their PA claims.

Why is Regular Review Important?

Regular reviews are necessary to determine if changes in PA listing or criteria are required. Changes in PA may be appropriate if a generic or biosimilar have been released, treatment protocols or utilization patterns have changed and the necessity for PA is no longer required, or utilization patterns have changed.

One of the market changes that payers will need to consider soon is the influx of generic GLP-1s starting in 2026, a high-volume moderate cost class of medications that currently require PA under most plans. Generic pricing could result in much higher volumes of prescribing, which, according to Amr Galal with Bridgewell Financial, is exactly what Richard Saynor, CEO of Sandoz, thinks could happen: “If you were selling [GLP-1s] at $40 or $50 a month, the market could be two or three times bigger in terms of the number of patients”.

Will it be cost effective for payers continue the current manual PA process for GLP-1 claims at those prices? Or will this be the catalyst for payers to move to an automated adjudication system (electronic prior authorization (ePA)) for GLP-1s and other high volume PA drugs to save on administration expenses while still managing access?

New drug submissions “are coming out at an all time high” according to the 2025 Express Scripts Canada Prescription Drug Trend Report. This includes areas where PA is likely, like cancer, rare disease, and inflammatory conditions. There are many more in the pipeline, particularly for cancer, and new indications for existing therapies.

Bottom line is that we can expect the PA landscape to continue to grow.

How Does This Compare to the U.S.?

The necessity for ongoing monitoring and review is not just a Canadian phenomenon. In the U.S. the regular review of the list of medications that require prior authorization is formalized in a process called Regular Prior Authorization Program Review. Each payer’s review process may differ, as plan design, risk tolerance, and internal criteria vary.

The process is addressed in the U.S. through initiatives like the American Consensus Statement, and the rationale is just as relevant in the Canadian context.

What’s Happening at the Patient and Plan Sponsor Level?

If you’ve ever had to navigate the prior authorization (PA) process in Canada, public or private sector, you know it can be time consuming and confusing. While drug evaluation committees do a critical job in managing PA there are opportunities for significant improvement in PA practices and processes among Canada’s private payers and many of Canada’s provincial public drug programs.

The easier the PA process is to navigate and adjudicate, and the more efficient, the better for patients and other stakeholders in the process, including plan sponsors. Plan sponsors pay for PA administration costs in their plan expenses and for absences.

When the PA process is complex to navigate and slow to respond because of manual processes, patient access to medication gets delayed. This means they may be at work but not fully functional or absent because they are waiting for treatment to help them return to work.

How We Can Do Better

Step 1: Understanding the current PA process for the payers you work with. Use the information and resources found at the Simplify Prior Authorization website.

Step 2: Become a member organization of the Prior Authorization Framework and Accreditation (PAFA) Program launched in November 2024. The PAFA Guide includes membership details, ways to improve efficiency in the prior authorization process, and how payers can become accredited. It also includes Q&A tips for advisors. It can be found on the PAFA website.

Payer accreditation is available to payers in two ways:

• Administration efficiencies – In their existing paper/fax PA claims administration process, and/or
• Electronic prior authorization – Through the implementation of electronic prior authorization that may include electronic completion and submission of claim forms and automated adjudication.

Step 3: Ask insurers that you work with if they are members of PAFA and if they plan to become accredited.

The PAFA’s September 23, 2025 webinar on Navigating the Changing Prior Authorization Landscape included an overview of PAFA accreditation, membership and more.