Originally published by our sister publication Specialty Pharmacy Continuum

By Myles Starr


To control the rising costs associated with treating cancer, many insurers are requiring prior authorization (PA) for specialty oncology medications. However, the need for PAs can delay necessary treatment and raise administrative costs for providers. But there is some relief at hand: A centralized, pharmacy-led PA process significantly reduced those delays and their attendant burdens on patients and health systems, according to a new study presented at the ASHP Pharmacy Futures 2025 meeting, in Charlotte, N.C.

“In our study, a program providing ambulatory clinical pharmacist [ACP] support improved the approval rates of both prior authorizations and appeals for specialty oncology medications by over 20% versus a PA process without ACP support [WACP],” poster presenter Young Kim, PharmD, BCMTMS, PACS, of Shields Health Solutions, in Stoughton, Mass., told Pharmacy Practice News.

The ACP- and WACP-led processes shared five key steps: 

1. A prescription is ordered by a provider to the hospital system specialty pharmacy. 
2. A patient support advocate (PSA) validates eligibility through a benefits investigation. 
3. A PSA preps a PA (or appeal) for submission. 
4. The PSA completes the PA (or appeal), documents the PA status and notifies a pharmacy liaison. 
5. The pharmacy liaison documents the PA status and alerts the provider of result. 

The ACP-led process contained a unique enhancement: In steps three through five, an ACP reviewed all new appeals and validated PA recommendations prior to submission. This simple change “increased patient access, decreased time to much-needed therapy, and [improved] patient healthcare and clinical outcomes,” Dr. Kim said.

The study took place at six oncology clinics located within a New York–based health system specializing in bone marrow transplant, genitourinary and thoracic solid tumors, and lymphoma and leukemia. (Dr. Kim declined to name the clinics.) PA approvals jumped from 71.1% (515/724) under the WACP process to 91.4% (3,091/3,381) after initiation of the ACP protocol. Furthermore, the appeal approval rate increased from 50% (23/46) to 71.9% (151/210) in the WACP versus ACP cohorts, respectively. In the ACP cohort, the average prescription turnaround time was 1.1 days. However, the “bulkier manual process and switch to a new platform did not allow for a formal direct head-to-head comparison of the two average prescription turnaround times,” Dr. Kim explained.

For both study cohorts, the top five medication classes that were requested for PA were androgen receptor pathway, Bruton tyrosine kinase, B-cell lymphoma-2, BCR-ABL tyrosine kinase and Janus kinase inhibitors. However, the classes of medications that were denied most frequently were not tracked.

Researchers did not quantify the specific burden to healthcare providers and systems that requests for PA caused. But others have done that work. “The 2024 American Medical Association prior authorization physician survey showed that 93% of the surveyed physicians reported delayed access to necessary care due to prior authorizations,” Dr. Kim noted. “Prior authorization also significantly increased costs to the healthcare system, as 88% of physicians reported higher overall resource utilization.”

The study’s retrospective observational nature and smaller cohort sample size were further limitations that Dr. Kim pointed out. He noted that in future studies, “the classes of medications most denied can certainly be explored to find any patterns or trends that may additionally help with the prior authorization process. However, this study still provides strong evidence that an ACP-led prior authorization process helps both patients and health systems.”




 

Dr. Kim reported no relevant financial disclosures.