The Current Prior Authorization Process

Welcome to our April 2026 update on electronic Prior Authorization (ePA)! This section describes the current prior authorization process, how it could be improved, and gives you up to date information on electronic prior authorization.

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.

Impact on Physicians and Their Patients

Access to claim forms – Not all forms are online and easily available to patients or physicians. As of 2025 some claim forms are now accessible online through technology solutions providers. Links to insurers and their PA form lists can be found under Resources on this site. Drug Access Canada also links to prior authorization forms for private insurers.
Even when claim forms can be completed electronically, the completed forms must be faxed or mailed to payers. Adopting electronic claim form completion is essential to reduce errors and reduce completion time. Claim forms require information and signatures from physicians and patients, sometimes patient records. Patient support programs coordinate form completion, both paper and electronic. Some patient support programs or drug access navigators have access to internal or external online claim form completion solutions. All PA claim forms should be available for electronic completion and submission to payers electronically.

For Payers

Once a PA claim is received by a payer, their adjudicators must manually review claim submissions to determine eligibility and request any further information requirements by mail. This delays decisions, particularly for claims where further information is required.
The administration costs for manually reviewing large volumes of claims is a burden that is passed on to plan sponsors. The introduction of PA for the GLP-1 class of medications has resulted in a significant increase in payer claims administration and expenses. The burden of PA claims adjudication will continue to increase. The majority of new drug development is in specialty, almost all of which will require prior authorization. Introducing efficiencies to reduce the burden is the only solution.

Other Challenges

Service commitments

Payers do not publish their service standards. This means that advisors and plan sponsors cannot take PA service commitments into consideration during a market study or at renewal. Service standards should include time to review a PA claim, request further information, and approve/deny. Payers should publish their service commitments and results.

Delays in time to reimburse or deny

Timelines vary by payer but the wait time for reimbursement decisions are typically at least 7-10 days not including mailing time, and in some cases decisions can take much longer. Time spent waiting for a payer’s reimbursement decision is time when a patient isn’t receiving optimal care for a disease that could be lifethreatening, or at the very least a disease where the patient is absent from work or not fully productive. With more treatments for oncology and other serious diseases under private plans, reducing response times for approvals should be a priority for payers.

Temporary changes in medication should be accommodated

Patients may be switched to a different medication temporary if their condition deteriorates or there is an exacerbation of their disease. This can happen in diseases like dermatology and Crohn’s disease. Patients should not be required to reapply for their original PA medication when they are well enough to do so if they return to their original medication within six months of a switch, and if longer, their application should be fast tracked.

Change of carrier should not impact a patient’s approval status

A new payer should honour an existing PA approval providing the new plan formulary includes the approved medication. The new payer should coordinate the receipt of a list of approved PA patients and their medications from the prior payer. This has been the responsibility of the advisor.

Denials should be clear and timely

Payers should clearly communicate the reason for denial to patients in a timely manner. Denials may be because the patient hasn’t tried a cheaper treatment option, due to missing information on the claim form, the prescribed medication is not on the plan’s drug formulary, or the drug has been prescribed off label. The denial notification should clearly state the process for appeal and provide a phone and email for further communication.

There is no public information that shares statistics on prior authorization practices or processes

There is no information on average time to approvals, rates of approvals, appeal rates, or information on patient evaluations. This information should be publicly shared on a non identifying, industry basis so that PA stakeholders are aware of the current service deliverables in PA, both publicly and privately.

Electronic Prior Authorization