Prior authorization may be required by a patient’s insurer either because the cost of the drug prescribed is relatively high or the drug has a high rate of use.
Although specialty drug claims make up only a small portion of the number of total drug claims submitted under group benefit plans, specialty drugs make up an increasing amount of total drug claims and expenditure for employers and other sponsors of group benefit plans.
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. This followed two years of no growth, and even a slight decline in 2022. 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.
Prior authorization is an insurers response to managing access to and costs for high-cost specialty drugs. It is in place to ensure that the medication prescribed is medically necessary and cost effective, i.e., either there are no suitable lower-cost alternatives available, or all other lower-cost alternatives have already been explored. Because the number of specialty drugs is increasing the PA process will become more commonplace.
Prior authorization is also used by public drug plans funded by provinces usually referred to as special authorization. Although the information on this site is primarily directed towards group insurance plans that include drug coverage, much of the information on this website will also be helpful if a patient has been prescribed a drug(s) that may be eligible under their provinces public drug formulary. To find out more about whether a specialty drug is eligible for coverage under a private or public drug program anyone can use the Is My Prescription Covered tool developed by the Canadian Skin Patient Alliance.
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.