Simplify Prior Authorization

August is Spinal Muscular Atrophy (SMA) Awareness Month. SMA is a rare, progressive neuromuscular disease that affects the motor nerve cells in the spinal cord. Every year, thousands of families face the challenges of managing SMA. Over the past decade, research has brought about new treatment options for SMA. To achieve maximum treamtent effects, a timely diagnosis and treatment intiation are critical.

Prior authorization or special authorization through private and public drug plans is required for access to many specialized therapies, including SMA therapies. Navigating access to essential medicines can be time consuming, frustrating, and challenging for patients and their families. SPA has developed key resources and guides to help patients understand and navigate the private payer PA process. Visit www.simplifypriorauth.ca today for help.

This month, let's join together to raise awareness about SMA and work towards making sure every individual living with SMA can access the treatment they need without unnecessary delays. For more information, contact us at [email protected]




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Has your claim been denied? If you have submitted a claim for prior authorization and your claim has been denied, here are some things you can do:
- Contact the physician or team that helped you submit your claim, as they may not have been notified. Your team may include patient support programs (PSP) or a drug access navigator (DAN). They may also be able to suggest appeal options with you.
- Ask whoever denied your claim why your claim was denied. This may mean contacting your group insurance company or a third party who reviewed the claim on their behalf. If it is your insurance company then you will need to know your group policy number and your member number, you may also need a claim number. Be prepared to give them the medication you were prescribed and the disease/condition your physician has diagnosed.
- Resubmit your claim - it may be worthwhile resubmitting the claim if it was denied. Additional medical information may be required, or the drug may have been prescribed 'off label'. Some insurers will consider 'off label' prescribing with additional medical evidence, such as peer reviewed articles or clinical trial results. Your physician, PSP, or DAN, can help you resubmit your claim with additional information that supports your physician's reasons for prescribing the drug to you for your specific circumstances.
You can find more tips on what to do if your claim is denied on our site https://www.simplifypriorauth.ca/i-am-a/patient-or-patient-group/my-claim-has-been-denied-by-my-insurer-what-should-i-do-now/

If you, a friend or family has been prescribed a medication requiring prior authorization, follow us for useful insights into the claims process. By the way, we won’t try to sell you anything, education and information is part of our mandate. Join the group and follow us! You can contact us through the SPA website. https://www.simplifypriorauth.ca




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"When a patient is prescribed a tailored treatment option for a moderate to severe form of a disease, they have often dealt with lengthy waits to get a diagnosis and tried first or second line therapies that did not to the trick or eventually failed them. Administrative delays caused by outdated, manual, and paper-based processes add insult to injury. Electronic prior authorization is a creative solution that can get patients started on a new treatment, and hopefully, back to their lives. The SPA website provides patients with additional support and resources in their journey." - Rachael Manion, executive director at the Canadian Skin Patient Alliance.

What is electronic prior authorization (ePA) and why is SPA working hard to encourage insurers to switch their claims process to ePA? Although ePA is not widely available today, insurers and other payers of specialty drug claims recognize the need to move in this direction. In June 2024, GreenShield, an insurance company that offers group benefits, and OkRx (www.okrx.ca), a healthcare technology solutions provider, were awarded an almost $1m grant from the Canadian Medical Association Foundation, Scotiabank, and MD Financial Group for the launch of ePA in Canada, including integration with electronic medical records (EMRs). EMRs are a critical part of the ePA process because they securely hold patient medical records, and physicians must provide limited access to some personal medical information from EMRs as part of specialty drug claims on behalf of their patients. The announcement of this grant is the ideal next step in physician support for reform of the current paper based, and lengthy, claims process for specialty medications. Once implemented, ePA will save time and money for everyone involved, and patients will receive access to their medications more quickly. You can read more about this grant and why ePA is important at our recent blog https://www.simplifypriorauth.ca/2024/06/23/significant-grant-awarded-for-development-of-electronic-prior-authorization-in-canada/.

Simplify Prior Authorization is committed to helping and supporting patients who are navigating the prior authorization process. If you, a friend or family has been prescribed a medication requiring prior authorization, follow us for useful insights into the claims process. By the way, we won’t try to sell you anything, information and education is part of our mandate. Join the group and follow us!




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What is the difference between a specialty drug and a regular prescription drug? Watch our doodly video on What Makes a Prescription Drug a Specialty Drug to find out more! Available in both English and French you can watch this and other videos about specialty drugs, benefit plans, and the prior authorization process anytime! Watch in English: https://www.youtube.com/watch?v=7H2D-QLxy5M Watch in French: https://www.youtube.com/watch?v=dLdAPJwXeco&t=1s

This video is part of our doodly video series providing more information about prescription drugs and prior authorization for patients. VIsit our website to see all the videos in this series. You can also find more patient information on the Simplify Prior Authorization website https://www.simplifypriorauth.ca/i-am-a/patients-and-group/

If you, a friend or family has been prescribed a medication requiring prior authorization, follow us for useful insights into the claims process. By the way, we won’t try to sell you anything, education and information is part of our mandate. Join the group and follow us!

Did you know that not all pharmacies can dispense specialty medications? Specialty medications, including high-cost drugs, as well as drugs that may require special handling or administration, are often only available from specialty pharmacies. Specialty drugs are used to treat complex diseases, and often require prior or special authorization (approval) before a patient can receive their medication. Insurer's or patient support programs may refer patients to a specialty pharmacy in order to receive a specialty medication. Find out more about prior authorization, specialty pharmacies, and other aspects of prior authorization under the Simplify Prior Authorization Resources page on our website www.simplifypriorauth.ca/resources

If you, a friend or family has been prescribed a medication requiring prior authorization, follow us for useful insights into the claims process. By the way, we won’t try to sell you anything, education and information is part of our mandate. Join the group and follow us!




#2024

According to the 2021 Canadian Cancer Statistics, an estimated 2 in 5 Canadians will be diagnosed with cancer in their lifetime. An average of 675 people in Canada will be diagnosed with cancer and 241 people will die from cancer each day in 2024 based on estimates from the Canadian Cancer Society. Prostate, lung and colorectal cancer are projected to be the highest rates of male cancers and breast, lung and colorectal cancers the highest for females.

Prior or special authorization is required for access to many specialized therapies either from provincial plans or group benefit plans, including some cancer treatment drugs. Navigating access to essential medicines can be time consuming and challenging for patients. Drug Access Navigators (DANS) play a key role in assisting patients to access their prescribed medications.

The Simplify Prior Authorization initiative has developed key resources to help both patients and prescribers understand and navigate the prior authorization process including information on DANs and cancer organizations across Canada that may be useful to those with a cancer diagnosis. Visit www.simplifypriorauth.ca for more information or contact us at [email protected].

Do you know what your group benefits coverage is for prescription drugs? Check out our video on Group Benefits Basics and Your Coverage for Prescription Drugs to find out -- available in both English and French!
Watch in English: https://www.youtube.com/watch?v=xW8JsFRLBlc
Watch in French: https://www.youtube.com/watch?v=GzVf5fFOQQQ

This video is part of our Doodly video series providing more information about prescription drugs and prior authorization for patients. You can also find more patient information and our other videos on the Simplify Prior Authorization site here https://www.simplifypriorauth.ca/i-am-a/patients-and-group/. You can also reach us at [email protected]

Have you heard of a drug access navigator (DAN)? DANs are experts in securing funding for drugs that are prescribed for patients from both public provincial drug plans and group insurance drug benefits. They work with physicians, usually oncologists, in cancer clinics across Canada. More recently, DANs can be available for patients with a diagnosis of multiple sclerosis (MS) and some other diseases where there are expensive treatments. If you or a family member have been diagnosed with cancer of MS it is likely that a DAN will provide you with support to help you secure funding for access to your medications. Here are some quick facts about DANs!

• DANs are also known by several other titles, like "medication reimbursement specialists".
• They are employed by hospitals to support physician prescribing and patient access to medications
• They come from a diverse healthcare background. They may be hospital pharmacists, pharmacy technicians, nurses, social workers, or none of these.
• There is are 4 regional associations that represent DANs.

Visit our site to find out more about DANs and others involved in prior authorization! www.simplifypriorauth.ca If you, a friend or family has been prescribed a medication requiring prior authorization, follow us for useful insights into the claims process. You can also email [email protected].




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If you or a loved one has been prescribed a drug requiring prior authorization (PA) by an insurer, or other payer, you and your physician may have needed to complete a paper claim form. Today, completed PA claim forms, whether they are completed electronically or in writing, can only be sent to insurers by mail or fax. After a review the payer will respond by mail or sometimes by phone if the drug is required urgently. This is unlike the claims process for lower priced non-specialty drugs that are reviewed electronically at the pharmacy based on the physician's prescription and group benefits coverage. Approvals, denials, and any patient out of pocket costs are handled at the pharmacy.

It is not surprising that the paper based system for PA claims takes much longer to prepare, submit and review, before patients receive a response for approval or denial of their claim. The administrative burden for everyone involved has grown over the years as the number of drugs that need prior approval have increased from just a few drugs before 2000, to hundreds today. The administration workload for physicians, patient support programs and those who review and pay claims, payers, has grown significantly.

The pressure on insurers and other payers to adopt a more streamlined administration approach, including an electronic, online solution for submitting PA claims and receiving news of an approval or denial has been growing in recent years, in part to the advocacy of the Simplify Prior Authorization initiative https://www.simplifypriorauth.ca ). This time last year the Canadian Life and Health Insurance Associatinon (CLHIA) that represents insurance companies agreed that "private payers in Canada recognize the need to move to digitization of a number of insurance processes that remain paper-based, including ePA (electronic prior authorization)" and that "the benefits for all stakeholders are high [and will] help relieve [the] overall healthcare administrative burden". When insurers and other payers prioritize improvements, the PA claims administration and communications process will improve and patients will be able to receive approvals for their claims more quickly.

A first generation electronic prior authorization solution is available in some disease areas to physicians and patient support programs, and to all payers. Once payers adopt this solution it will replace most steps in the current paper-based prior authorization process and can improve the logistics and timelines for prior authorization. Find out more about prior authorization and this exciting new solution on our site! https://www.simplifypriorauth.ca/electronic-prior-authorization-epa/what-is-electronic-prior-authorization-epa/

If you, a friend or family has been prescribed a medication requiring prior authorization, follow us for useful insights into the claims process. Join the group, follow us, and share with a friend! You can also find out more about us at www.simplifypriorauth.ca.

What makes a prescription drug a specialty drug requiring prior authorization? Specialty drugs are usually drugs whose price is greater than $10,000 annually per patient. These drugs, and a few others, are usually subject to prior authorization, which means your insurer will want to review the details of your condition and other medications you have already used before they will approve coverage for it. People who are prescribed specialty drugs that require prior authorization often have a complex and chronic disease such as Cancer, Rheumatoid Arthritis, Psoriasis, Multiple Sclerosis, Crohn's and Colitis, and some other autoimmune diseases.

Why do insurers use prior authorization? All insurers use prior authorization to manage who is approved for use of specialty drugs. Specialty drugs are expensive, and in for most conditions patients should be prescribed more cost effective therapies before a specialty drug. Only patients with a specific disease profile, or those who have tried and failed to respond to other less expensive therapies will typically be approved for a specialty drug. Each insurer will have their own criteria that must be met by patients before their claim is approved.

Visit our site to find out more about specialty drugs and prior authorization! www.simplifypriorauth.ca

If you, a friend or family has been prescribed a medication requiring prior authorization, follow us for useful insights into the claims process. You can also message us if you have any questions.




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Do you know the difference between a deductible and copay? Group benefits and the prior authorization process can be full of terms that you may not be familiar with. Check our Glossary page of the SPA site for definitions and explanations of terms related to group benefits, prior authorization, prescription drugs, and more! https://www.simplifypriorauth.ca/glossary/ =ALL

If you, a friend or family has been prescribed a medication requiring prior authorization, follow us for useful insights into the claims process. Join the group and follow us! You can also find out more about us at www.simplifypriorauth.ca

Why is prior authorization needed for some medications under your group benefits plan?
Prior authorization may be required if the medication is expensive or if the insurer will only pay for it under specific circumstances. Using prior authorization, an insurer can be confident that the medication prescribed by a physician, usually a specialist, is appropriate for the patient's disease, and the stage of disease. They will also check to make sure that other lower cost medications have already been tried before the more expensive medication is approved. Patients may also need to use a pharmacy the insurer has an agreement with. This may be because the medication needs special storage and handling that isn't available at the patient's local pharmacy, or that the medication is complex to administer and requires one on one instruction for the patient, or because the patient will have to go to a location that can give the patient their medication regularly, like an infusion center.
You can also find out more about us at www.simplifypriorauth.ca
If you, a friend or family has been prescribed a medication requiring prior authorization, follow us for useful insights into the claims process. By the way, we won’t try to sell you anything, it is part of our mandate. Like the page and follow us!



#2024

Do you have a group benefit plan at work? Do you know what prior authorization is?
If you have a group benefits plan at work and you have received a prescription from your physician then you'll know that claims for prescription drugs are usually approved when you present your prescription to your local pharmacy. When a patient gives their pharmacist their group policy information the pharmacy computer software communicates with insurer claims systems to review and approve or deny prescription claims. That works well for most medications, but some medications will need further review, and these claims are subject to prior authorization. The purpose of the prior authorization process is to give insurers additional information to determine whether your medication is eligible for reimbursement under your plan. Sometimes patients may also be required to use a different pharmacy to receive their medication either because of how you need to take the medication or because of special storage requirements.
You can find out more about prior authorization and the claims process at www.simplifypriorauth.ca.
If you, a friend or family has been prescribed a medication requiring prior authorization, follow us for useful insights into the claims process. It is part of our mandate. So like the page and follow us.




#2024

March is Colorectal Cancer Awareness Month - Did you know that colorectal cancer is the third most common cancer type worldwide? The good news is that early detection and treatment make colorectal cancel one of the most treatable and preventable forms of cancer. The Simplify Prior Authorization Resources page contains some helpful information for patients navigating the prior authorization process for cancer treatment drugs and other information that may be helpful. You can find out more on our resource page: https://www.simplifypriorauth.ca/resources/

You can also find more resources on colorectal cancer at Colorectal Cancer Canada https://www.colorectalcancercanada.com

Let’s do what we can to help raise awareness, promote early detection, and make treatment easier.

If you, a friend or family has been prescribed a medication requiring prior authorization, follow us for useful insights into the claims process. By the way, we won’t try to sell you anything, it is part of our mandate. Like the page and follow us! You can also find out more about us at www.simplifypriorauth.ca

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Looking for insurer forms for prior authorization claims? The SPA site has you covered!

Find links to major insurer prior authorization resources and claim forms under the Resources tab of our site www.simplifypriorauth.ca/resources. You can also find other important information related to prior authorization under the Resources tab, including what to do if a claim is denied by your insurer, and provincial drug coverage programs.

Some insurers will have information about making a prior authorization claim on their website that is publicly available or through their plan member portal, including a list of drugs requiring prior authorization. Looking for something else? Let us know in the comments what other resources you are looking for!

If you, a friend or family has been prescribed a medication requiring prior authorization, follow us for useful insights into the claims process. By the way, we won’t try to sell you anything, it is part of our mandate. Like the page and follow us! You can also find out more about us at www.simplifypriorauth.ca

#2024

Why is prior authorization needed for some medications under your group benefits plan?

Prior authorization may be required if the medication is expensive or if the insurer will only pay for it under specific circumstances. Using prior authorization, an insurer can be confident that the medication prescribed by a physician, usually a specialist, is appropriate for the patient's disease, and the stage of disease. They will also check to make sure that other lower cost medications have already been tried before the more expensive medication is approved. Patients may also need to use a pharmacy the insurer has an agreement with. This may be because the medication needs special storage and handling that isn't available at the patient's local pharmacy, or that the medication is complex to administer and requires one on one instruction for the patient, or because the patient will have to go to a location that can give the patient their medication regularly, like an infusion center.

You can also find out more about us at www.simplifypriorauth.ca

If you, a friend or family has been prescribed a medication requiring prior authorization, follow us for useful insights into the claims process. By the way, we won’t try to sell you anything, it is part of our mandate. Like the page and follow us!




#2024

Do you have a group benefit plan at work? Do you know what prior authorization is?

If you have a group benefits plan at work and you have received a prescription from your physician then you'll know that claims for prescription drugs are usually approved when you present your prescription to your local pharmacy. When a patient gives their pharmacist their group policy information the pharmacy computer software communicates with insurer claims systems to review and approve or deny prescription claims. That works well for most medications, but some medications will need further review, and these claims are subject to prior authorization. The purpose of the prior authorization process is to give insurers additional information to determine whether your medication is eligible for reimbursement under your plan. Sometimes patients may also be required to use a different pharmacy to receive their medication either because of how you need to take the medication or because of special storage requirements.

You can find out more about prior authorization and the claims process at www.simplifypriorauth.ca.

If you, a friend or family has been prescribed a medication requiring prior authorization follow us for useful insights into the claims process. It is part of our mandate.

Denise is the co-founder of the Simplify Prior Authorization (SPA) initiative and is involved in every aspect of its activities. She is also an expert in group benefits and the private healthcare sector, having worked in the industry for more than 35 years. Through Connex Health Consulting, she delivers educational programs to those working in employee benefits and regularly publishes blogs and podcasts on topical issues in benefits. Denise has also written many published articles on benefit issues, and co-authored several white papers, including on prior authorization, which led to the development of the SPA initiative.

A passionate advocate for quality care for patients, Denise currently serves on the Board, the Finance, Executive, and Governance Committees, and is Vice Chair of the Temiskaming Hospital in New Liskeard, Ontario.

Denise is committed to using her network and social media channels to deliver insights into prior authorization to patients and other healthcare stakeholders, and working for industry level improvements in the prior authorization process in group benefits.

Follow us to learn more about prior authorization of group benefit claims.. You can also find out more about Simplify Prior Authorization at www.simplifypriorauth.ca




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