Insurer and Pharmacy Benefits Manager

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Prior Authorization Stakeholders and Prior Authorization

As more specialty drugs comes to market, the list of drugs subject to the prior authorization process under group benefit plans grows. As a result, advisors, plan sponsors and healthcare professionals are becoming more exposed to the prior authorization process, and with experience they have developed knowledge, understanding, and their own perspective about prior authorization and the prior authorization process. The 2020 White Paper on Private Payer Prior Authorization and subsequent dialogue with prior authorization stakeholders has provided insight into other prior authorization stakeholders for this section of the website for payers.

Advisors

Advisors have come to expect that insurers will restrict access to specialty drugs through prior authorization.

  • They understand that the prior authorization process is in place to ensure that the medication prescribed is necessary and appropriate, i.e., either there are no suitable lower-cost alternatives available, or all other lower-cost alternatives have already been explored.
  • They believe this process ensures overall healthcare costs are actively managed and ensures that most employers and other plan sponsors continue to offer drug benefits to their members without an annual or lifetime maximum.

One of the most important roles that plan advisors play in prior authorization is on change of carrier. Since typical grandfathering rules do not apply in the case of those with prior authorization claim approvals, it is incumbent on them to coordinate a list of prior authorization claimants and pertinent claims details from the incumbent to the new carrier. This will ensure that plan members or their dependents who have been approved under a prior authorization provision do not lose approvals and coverage on change of carrier.

According to one plan advisor ‘This can be particularly challenging if the new carrier does not include a prescribed prior authorization drug on their formulary or if the plan sponsor changes from a traditional to a non-traditional insurance arrangement where more than one carrier is involved. If the drug is not on the formulary for the new carrier, then coverage may be lost.’

Unless a plan advisor has been involved with a prior authorization claim they do not have any training on the process or the challenges that patients can face during the claims process to access the drug(s) they have been prescribed. Advisors will only gain an understanding of the process and its challenges if they have become involved in a prior authorization claims situation.

One advisor who has had this experience believes changes are overdue. ‘Patients have no concept of specialty drugs or prior authorization, and they can become very overwhelmed by the process during a time when they are particularly vulnerable. We need a solution that makes the process easier for patients and others involved in prior authorization.’

Payers have an opportunity to work with advisors to understand specialty drugs, grandfathering provisions, and the prior authorization process before they are asked to assist with a prior authorization claim by a plan sponsor or a plan member.

Plan members and prior authorization

Until a plan member is prescribed a drug that is subject to prior authorization, they are largely unaware of the additional process requirements for prescription drugs requiring prior authorization. Ideally, the patient’s prescriber will be familiar with payer requirements regarding prior authorization and will know that they should prescribe typically older, less expensive drugs before prescribing a specialty drug. They should also:

  • Know that the drug they are prescribing is subject to prior authorization
  • Understand the basic requirements for eligibility
  • Be familiar with the private payer prior authorization claims process for the drug they are prescribing
  • Take the time to inform their patient and explain the process
  • Refer the patient to a patient support program (PSP) or drug access navigator (DAN), in the case of cancer drugs, for the patient to receive guidance through the prior authorization claims process.

If the prescriber does not understand the payer’s requirements and does not have the information to educate and refer their patient, then the prior authorization process can be very confusing and frustrating for the prescriber and their patient.

Even with some guidance from a physician’s office, prior authorization and drug coverage for specialty drugs can be difficult to navigate.

Most plan members will probably need some help from an expert in prior authorization who will work with a patient’s best interest in mind to achieve a timely and fair reimbursement decision.

The frustration and anxiety that can accompany a serious diagnosis that requires a specialty drug with an extensive administrative process could be mitigated with adequate education in advance of any specialty drug claims.

Payers have an opportunity to work with prescribers, plan sponsors and advisors to improve plan member understanding of specialty drugs and the prior authorization process. This could be through the group benefits plan portal, in plan member booklets, or by providing plan member materials through the plan sponsor or plan advisor.

Prescribers and prior authorization

The prior authorization claims process begins when the prescriber prescribes a drug to their patient.

  • The prescriber, usually a physician, may or may not know that the drug they are prescribing will require prior authorization by the patient’s group benefits provider.
  • If it is a drug(s) they have prescribed to other patients, they should have a good idea whether the drug(s) will be covered by a public drug program in the patient’s province, whether it should be submitted to the group benefits provider, or whether the patient will need to apply to a compassionate program offered by the pharmaceutical manufacturer.

If the drug prescribed is not covered by any provincial drug plan and requires that the patient submit a prior authorization claim for reimbursement to their group benefits provider, then the prescriber will also be required to prepare documentation that will support the claim.

Is My Prescription Covered? is a free and interactive drug coverage finder from the Canadian Skin Patient Alliance. We have also developed some tips for patients in Do You Have Prescription Drug Coverage.

The staff at the prescribing physician’s office may provide guidance to patients on how the claims process will work for the drug they are prescribed. They may have staff who will work with the patient to complete necessary claim form(s) and other documentation that will need to be completed.

They may also refer the patient to outside assistance to help with preparing their claim through a patient support program (PSP), or a drug access navigator (DAN) for oncology patients.

Prior authorization is challenging for prescribing physicians. Here are some of the reasons:

  • Access to the correct claim form for the drug and indication they are prescribing is not always easy
  • The heavy administrative burden of completing prior authorization claims and assisting their patient
  • Concerns that their professional opinion on which drug is best for their patient is being questioned.

Even when staff at the physician’s office provide patients with assistance with their prior authorization claim or the patient is referred to a PSP or DAN there is an administrative burden on the prescribing physician. Resources like Drug Access Canada reduce some of this pressure by providing links on their site to prior authorization forms for private insurers. If your claim forms are not on the site, you can contact the administrator directly and arrange for posting of your prior authorization claim forms.

Drug access navigator (DAN) – (cancer therapies)

Also known as drug access facilitator or medication reimbursement specialist, DANs work to connect a patient with the medication or treatment they require.

Currently DANs are mostly found in cancer clinics but are increasingly found in other diseases like Multiple Sclerosis and Cystic Fibrosis.

If the plan member is being treated at a cancer centre, they should ask their physician if there is a DAN or someone in a similar role that can help them through the claims process. A pharmacist or social worker may do the role of the DAN even by a different title. You can find out more about DANs through their provincial associations and under Resources on this site.

Patient support program (PSP)

Patient Support Programs are services delivered by PSP companies and funded by pharmaceutical manufacturers. The programs are designed to provide features and support for patients on specific medications. As advocates they help patients navigate the complexities of reimbursement.

PSPs may also have funds available to them through a patient assistance program to help with the cost of medication if the plan member does not have coverage elsewhere or if the drug is not completely covered either through a provincial drug plan or a group benefits plan.

Programs that exist can be very specific in terms of criteria for enrollment. As such, the prescribing physician will be engaged to ensure that only those that qualify are referred.

The prescribing physician should be able to direct the patient to the PSP for the drug they have prescribed. If it is not clear whether there is a PSP, then contact can be made directly to the pharmaceutical manufacturer through their toll-free number or on the manufacturer’s Canadian website. More information on PSPs is available under the Resources page of this website.

For oncology drugs, the physician may also refer the plan member to a drug access navigator (DAN), who are publicly funded, and will be able to help with enrollment if a manufacturers program does exist.

Pharmacy

Community Pharmacy – if the prescribing physician does not tell the plan member or they are not aware that the drug prescribed requires prior authorization, then the plan member’s community pharmacy may be the one to inform the plan member/patient that the drug requires prior authorization.

In that case the plan member is typically redirected to the prescribing physician’s office to discuss the prior authorization status of the drug prescribed. The physician or their staff may either assist the plan member or direct them to a specialty pharmacy, PSP, or DAN.

A specialty pharmacy may work closely with physicians and patients on preparing a prior authorization claim. If the prescribing physician works closely with a specialty pharmacy, the physician may refer the plan member to the specialty pharmacy for assistance in preparing their claim.

In some situations, the specialty pharmacy may provide assistance to the patient and prescriber that results in an approval for the drug(s) prescribed, but the payer may require that the payer’s specialty pharmacy provider/network dispense the drug. When this occurs the original specialty pharmacy is not reimbursed for the navigation assistance they have provided to the patient. This is a gap that should be addressed by payers.