Streamlining Prior Authorization to Unlock Specialty Medication Access

When Marie D’Orsaneo’s rheumatoid arthritis worsened, her doctor prescribed Rituxan, an expensive injectable drug. However, her health plan’s approval process dragged on for weeks, causing her condition to deteriorate. She eventually had to quit her job, move in with family, and seek inpatient care. 

Featured in an NBC News segment in January 2013 about the high cost of specialty drugs, D’Orsaneo’s experience is unfortunately common, and the situation for patients has only worsened since then. Specialty drugs, due to their high cost and specific handling and administration needs, often require prior authorization (PA). According to research published in *Arthritis Care & Research*, 71% of infusion therapies for rheumatologic conditions now require payer approval. 

The growing costs aren’t the only issue—doctors are increasingly burdened by the process. A significant 80% of physicians report an increase in prior authorization demands, regardless of whether the drug falls under pharmacy or medical benefits. 

For healthcare providers, this process isn’t just an inconvenience; it’s a serious issue. Nearly 90% of doctors surveyed by the American Medical Association (AMA) describe the administrative burden of prior authorizations as high or extremely high. 

Challenges with Prior Authorization

The complexity and costs of specialty medications create significant barriers for patients needing essential therapies. An increasing number of prior authorizations, constantly changing payer rules, and limited provider access to patient health and benefit information further exacerbate these challenges. 

The process often begins with a frustrating web search to determine if a specific medication requires prior authorization. A typical scenario involves a patient with a complex disease visiting a provider, who quickly identifies the necessary treatment. However, determining if the patient’s insurance will cover the treatment becomes a challenge. Staff members scramble to search through insurance requirements, recall previous approvals, and determine whether the medication falls under pharmacy or medical benefits, which insurers handle differently. 

Meanwhile, others make frantic calls to payers and search insurance websites for coverage information and updates, leading to considerable delays and frustration. 

According to the AMA’s *What Doctors Wish Patients Knew* series, patients can wait days, weeks, or even months for treatment due to prior authorization requirements. The AMA argues that “existing processes present significant administrative and clinical concerns.” 

One of the most frustrating obstacles is confusion over whether specialty drugs are covered under medical or pharmacy benefits. For example, infusions, in-office injections, and chemotherapy are sometimes classified under medical benefits. To complicate things further, nearly half of all insured individuals have a separate benefit tier for specialty drugs. 

Challenges for Specialty Pharmacies

Specialty pharmacies face significant hurdles in obtaining prior authorizations and ensuring patients receive their medications promptly. These barriers, though less recognized, delay patient access to essential treatments. 

A common issue is the frequent misrouting of specialty medications to non-specialty pharmacies, which often cannot fill these prescriptions. According to a study by DrFirst, specialty pharmacies are 30% more likely to successfully fill a rheumatologic medication than non-specialty pharmacies. However, over a quarter of high-cost specialty medications are mistakenly sent to non-specialty pharmacies, leaving patients without their necessary treatments. 

For physicians prescribing these complex therapies, not having real-time access to benefit and pricing information, copay savings, and financial assistance can severely limit their ability to provide optimal care. Despite industry efforts to improve price transparency, such as the ONC’s HTI-2 proposed rule requiring health IT systems to include immediate pricing access by 2027, challenges persist. Even when EHRs offer price transparency, the information is often incomplete. Providers might know the ideal treatment but lack information on insurance coverage, prior authorization requirements, or available pricing options. 

When this critical information is available at the point of care, providers and patients can discuss alternative treatments if insurance coverage is uncertain, preventing prescription abandonment due to high costs. In fact, 83% of consumers in a DrFirst survey reported that discussing price with their doctor helped them find an affordable treatment option. 

Another concern is the underutilization of hub services, designed to simplify the medication onboarding process by acting as intermediaries between patients, providers, and pharmacies. These services provide education and guidance to ensure patients start and stick with their therapies. However, many patients are either unaware of these services or do not fully engage with them. 

These barriers result in significant risks for patients, including: 

• Care delays: 94% of physicians report that prior authorization often leads to care delays. 
• Care disruptions: 89% of physicians say prior authorization interferes with continuity of care. 
• Adverse outcomes: 33% report that prior authorization has led to a serious adverse event for a patient in their care. 

Improving the Process

To address these challenges, electronic prior authorization needs to be fully integrated into healthcare workflows. An electronic solution should streamline the entire process by offering real-time medical benefits and automating the PA process end-to-end. 

Providers should adopt platforms that leverage AI, machine learning, and robotic process automation to simplify complex benefit pricing and processes for both pharmacy and medical benefits. A platform that actively engages patients and offers unified medication management can also help facilitate access to necessary therapies.