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 healthcare costs under group benefit plans. The medication you have prescribed to a patient is likely to be a specialty drug requiring prior authorization if the cost exceeds $10,000 annually.
Patient support programs exist to help patients navigate prior authorization claims and reimbursement and may also provide financial assistance to patients. Find out from the drug manufacturer if a patient support program exists for the drug you are prescribing to your patient.
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. Many claims are declined because of missing information. Be sure all the required sections are completed and sign the claim form.
Claims are often approved on appeal. Encourage your 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’. Patient support programs may also provide financial assistance to patients.
In 2026 electronic prior authorization will become an option with some insurers 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.