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.
Prior authorization (PA) adjudication criteria is proprietary for payers. The PA claims process does not need to be. Every payer, larger or small, and every insurer, third party payer or pharmacy benefit manager, currently has a manual PA claims review and adjudication process that is ineffecient and expensive to operate. Plan sponsors are the ultimate payers of the PA process through their claims administration expenses.
Although changes in prior authorization, including ePA, will reduce costs and improve access to medication, payers have been reluctant to change their administration practices and policies to adhere to a common framework or to adopt ePA.
Simplify Prior Authorization advocacy and the work of others has encouraged dialogue and led to a consensus amoung payers that prior authorization needs to change. In the May 2023 article in Benefits and Pensions Monitor on ‘Why It’s Time to Change the Prior Authorization Process’, Joan Weir, vice-president, group benefits, Canadian Life and Health Insurance Association said “Private payers in Canada recgonize the need to move to digitization of a number of insurance processes that remain paper-based, including ePA. The benefits for all stakeholders are high and, at a time when access to medical resources can be difficult, help relieve overall health administrative burden”.
When payers introduced a PA requirement for GLP-1s, they were overwhelmed with the number of PA claims. This, perhaps more than anything else, has elevated the priority of ePA, which is now on their agendas. Look to mid 2026 before the first of these solutions are available on a limited basis in the marketplace.
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.