There are multiple stakeholders with an interest in prior authorization (PA), and some of them would benefit from assistance to understand the process. This site is intended to provide information and education to those stakeholders and demystify the process. In the future other sections containing more information about prior authorization will be added to the site.
This section is intended for insurers and pharmacy benefit managers (PBMs), payers, who are responsible for adjudicating prior authorization claims. It highlights how other prior authorization stakeholders experience prior authorization and how they perceive the current process and practices that are in place.
Advisors, plan sponsors, and healthcare professionals are aware that there is an increasing number of total drug claims and expenditures on specialty drugs. In addition to claims experience and renewal reports from insurers, the annual reports published by pharmacy benefit managers (PBMs) Express Scripts and TELUS have done a good job at educating some prior authorization stakeholders on the costs and trends associated with specialty drug trends.
In 2025, both Express Scripts Canada and TELUS Health reported an increase in specialty drug spending.
Express Scripts Canada reported an increase of 15.7% in the percentage of members making at least one claim for a specialty drug and a 9.3% increase in the percentage of claims for a specialty drug.
TELUS Health reported that specialty drugs made up 32.8% of the total eligible amount, resuming an upward trek from 31.2% in the previous year. In 2022 TELUS Health predicted that specialty drugs would account for almost half of the average eligible amount per certificate. Recent trends for both adjudicators indicate that while significant, the total eligible amount for specialty drugs remains well below 50%.
The rising trend for specialty drugs can be explained by the increasing number of specialty drugs, and newly approved indications for drugs that target inflammatory, skin conditions, and cancer as well as the growing trends for TRIKAFTA, a high-cost drug for the treatment of cystic fibrosis. The rise in speciailty drug spending is concerning to payers, advisors, and plan sponsors, but it is not the only challenge in specialty drugs, where prior authorization is required. Practices and processes result in slow approval rates and added administration expenses from manual review. These need to be updated to deliver efficiencies. Vocal advocates of change include Simplify Prior Authorization and the Prior Authorization Framework and Accreditation (PAFA) Program.
While payers have increased awareness of specialty drug trends, information and education on the prior authorization process is not as widely available, particularly for those impacted by prior authorization.
There are many benefits for insurers and PBMs who are looking to modernize and make their prior authorization process more efficient. The Prior Authorization Framework and Accreditation (PAFA) Program provide a structured approach to improving PA by giving payers the opportunity to receive accreditation, emphasizing communication, consistency, efficiency, and transparency.
When private and public payers become accredited through PAFA, their organizations position themselves as leaders in improving communication and workflow for PA claims. Canada’s prior authorization landscape will be more efficient when timeliness for patient access to medications improve and the administrative burden for all stakeholders is reduced. Further innovation through electronic completion and submission of claim forms through electronic prior authorization, and automating adjucation for some medications will further improve the process and result in efficiencies that will benefit all stakeholders and drive down current administration costs for processing specialty drugs claims requiring prior authorization.
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.