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If you represent a patient support/assistance program (PSP) then you will be familiar with at least some of the information contained in this website, particularly in this section. The goal of this site is to provide a central resource on prior authorization for all prior authorization stakeholders.
Prior authorization is typically required for specialty drugs (drugs over $10,000 annually per patient). Specialty drugs make up an increasing percentage of expenditures for employers and other sponsors of group benefit plans. Prior authorization is in place to ensure that the medication prescribed is necessary and appropriate to manage over healthcare costs under group benefit plans.
Most patients you encounter as a patient support/assistance program will have been prescribed a specialty drug requiring prior authorization by their physician. Insurance companies or pharmacy benefit managers (payers) will often have a prior authorization drug list on their website for drugs that require prior authorization. Some may include the required claim forms that can be printed for your use, but others may not.
Insurers designate some drugs under group plans as specialty drugs that require prior authorization, or prior approval, before the drug is dispensed. The list of drugs that require prior authorization can vary between insurance policies and insurance companies.
Claim forms can be found either on the insurer website or by contacting the insurer directly. Claims are submitted via fax or mail, and often take 7-10 days for a decision to be made.
Encourage the patient to ask their insurer why their claim was denied. Appeals may require additional medical documentation or more information, the drug prescribed may not be in the insurer’s list of eligible drugs or the drug may have been prescribed ‘off label’.
Electronic prior authorization is now an option in Canada. It is a more efficient claims process for all stakeholders and is gaining support among private payers.
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.
