The Current Prior Authorization Process

Welcome to the electronic Prior Authorization (ePA) information section! This section is focusses on the current prior authorization process and how it could be improved. It contains information about electronic prior authorization, the challenges it will solve in the current, largely manual process and some of the barriers to adoption.

The Current Prior Authorization Process

The prior authorization process has many challenges, the most significant of which are the administrative and financial burden on medical practitioners, patient navigators, patients, and payers. Many of these issues were identified in the 2020 Report on Private Payer Prior Authorization in Canada developed by Connex Health and the Pangaea Group.

For Physicians and Their Patients

Submitting a prior authorization claim means securing and completing the appropriate claim form for the patient’s disease and the drug(s) prescribed, plus gathering relevant medical records.

Once complete, the claim is submitting by mail or fax to the payer (insurer or PBM).
Patient Support Programs or Drug Access Navigators are often involved in the process to ease the administrative burden for prescribers and their patients.
Even with assistance this can be an administratively burdensome and time-consuming process.

As a result, there can be a significant time lag between prescribing and patients receiving access to their medication.

For Payers

An initial drug review is conducted by an internal committee to establish prior authorization criteria for a drug before claims for that drug are accepted.

The current prior authorization process requires payer personnel to manually review claim submissions for prior authorization eligibility based on the payer’s criteria.
When information is unclear, missing, or when further details are required then it is typically requested by mail or fax.

This process is not efficient and with an increasing number of drugs requiring prior authorization, the administration to process for claims adjudication is creating an increasing financial burden for payers and other stakeholders, including plan sponsors.

Finding Claim Forms

This can also delay the current prior authorization process. Claim forms may be available on the insurer’s website, but not for all insurers.

When they are not, the patient must contact the insurer to request the claim form for each of the drugs that are prescribed and the condition that the drug will be used to treat.

Links to insurers and their prior authorization form lists under Resources on this site. Drug Access Canada also links to prior authorization forms for private insurers.

Decision to Reimburse or Deny

The timeline for a claim’s decision will vary by payer, but the wait time is typically at least 7-10 days, or longer.

Patients may receive a letter in the mail, or if the drug(s) prescribed is urgently needed, which is common for cancer medications, then patients may receive a decision more quickly.

When a drug is urgently needed, then a decision may be made more quickly, and patients may receive a phone call from the payer.

Eligibility Critera

It is important to note that prior authorization drug eligibility criteria can change between insurers, therefore approvals for a prior authorization drug can vary by payer.

Once the claim is approved the patient may be directed to their local pharmacy to pick up their medication, or a specialty pharmacy chosen by their insurer, or they may have to access their medication in hospital.

Denials

When the claim is denied, the patient should expect to know the reason and can ask for a written explanation. Some of the reasons a claim may be denied include:

Missing information that is required
The claim may be for a drug that is not eligible under the group policy’s drug formulary, or
The drug may be prescribed off label, which means it has been prescribed for treatment of a disease or condition that has not been approved by Health Canada.

If the patient or their prescriber do not agree with the decision, then they can appeal to the payer. The process for this varies by payer.

Electronic Prior Authorization