Patient Support Program

An insurance representative reviewing health benefits options with a client.

Insurers and Pharmacy Benefits Managers (Payers) and Their Role ​

As a PSP you will already be aware that 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.

You may not know that the list of prior authorization drugs is usually created by an internal review committee, and sometimes external medical experts, who review each drug against clinical guidelines and decide on the insurers criteria for reimbursement.

As you will know, in general, specialty drugs that require prior authorization are usually higher priced drugs that are used on a limited basis. These drugs are often used when other treatments have not been successful, when the disease is uncommon, or when the drugs are used in cancer therapy. To manage costs for specialty drugs under group plans, and ensure appropriate access to medications, insurers review these claims before they are approved through a prior authorization process.