Specialty drugs are often drugs where the annual cost exceeds $10,000 annually and are used in the treatment of complex conditions. Prior authorization will be required by the insurance company or pharmacy benefits manager (PBM) adjudicating the claim. The patient and their physician will need to complete a claim form and submit it and any medical information that is required to their insurer or PBM for review. The claim form may be unique for the drug prescribed.
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.
In 2026 electronic prior authorization will become an option with some insurers in Canada. Patient support programs exist to help patients navigate prior authorization claims and reimbursement.
Claims are often approved on appeal. Encourage plan members 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.
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.