Insurer and Pharmacy Benefits Manager

A happy couple meeting with a pharmacy benefit manager.

Why The Interest in Prior Authorization?

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. Reporting on specialty drug spend in 2022 included:

  • Express Scripts Canada reported that specialty drugs made up only 0.9% of total claims, but that they accounted for 29% of total drug spend in group drug plans, up 6.8% from the previous year.
  • TELUS Health reported that specialty drugs made up 34% of the total eligible amount despite only making up 1.4% of total claims.

TELUS Health has publicly predicted that if current trends continue that specialty drugs will account for almost half of the average eligible amounts by 2026. This is concerning to payers, advisors, and plan sponsors.

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.