The rise of prior authorization

While many patients and physicians feel that it is increasingly difficult to get insurance to cover new treatments, a JAMA Viewpoint (Resneck 2020) demonstrates this trend numerically.

 Prior authorization requirements increased from 8% to approximately 24% of covered drugs on Medicare Part D plans between 2007 and 2019.1 In 4 therapeutic classes (including antidepressants, autoimmune disease immunotherapies, multiple sclerosis agents, and antineoplastic drugs for chronic myeloid leukemia), application of prior authorization/step therapy on commercial formularies increased from 35% of single-source drugs approved for at least 1 year in 2011 to 67% in 2016.2 Physicians expect challenges when prescribing newer specialty drugs, but major formularies in some instances now require prior authorization/step therapy even for established generic products that have no obvious lower-cost substitutes, including topical corticosteroids, oral immunosuppressive agents, HIV antiretroviral medications, sulfonylureas for diabetes, and oral antineoplastic drugs for cancer.

These prior authorization requirements impose significant cost on providers.

A 2018 survey of 1000 practicing physicians across multiple specialties found that they reported completing a mean of 31 prior authorizations for medications and procedures per week, with a mean of 15 hours in time spent seeking authorizations.