Megan examines how prior authorization execution has become a strategic differentiator for biopharma brands as formulary changes and expanding utilization management put more pressure on access. She argues that building consistent, scalable prior auth execution can reduce therapy delays, improve determination time, and strengthen brand performance across the product lifecycle.
To learn more about CoverMyMeds' prior authorization solution, download their case study: From Decline to Growth: How One Brand Expanded Access in Late Lifecycle.
Read on for Megan's insights.
When Access Tightens, Prior Authorization Execution Becomes the Differentiator
By Megan Wetzel, Vice President of Product, Access and Affordability, CoverMyMeds
As coverage criteria shift and provider offices are asked to manage more complex and higher volumes of prior auth requests, even minor gaps in the process can delay or prevent therapy starts. What has changed materially in the past year is the scale and urgency of this pressure. Utilization management has expanded across major therapeutic categories, and approval rates in several competitive classes have declined as criteria shifts. This creates a prior authorization environment that demands more consistent strategies than most brands are currently equipped to support.
The prior auth process is far more than the traditional prescriber-payer transaction it is often assumed to be. It functions as a multi-stakeholder coordination effort that simultaneously draws in prescribers, pharmacy teams, and health plans. Brands that treat it as a two-way transaction often discover that the gaps are wider than expected.
Prior authorization requirements will keep evolving. The question is whether brands are built to absorb that evolution without losing ground on therapy starts. Let's look at two recent examples from brands we supported at CoverMyMeds.
When formulary changes, prior auth becomes the access pathway
Formulary changes rarely come with runway. A plan moves a brand to exclusion, and the effects hit the pharmacy counter and the prescriber workflow at the same time. This was the case recently when a major health plan moved a brand that had strong positioning in a competitive class to exclusion. The prior auth requirements climbed as prescriptions that had once adjudicated cleanly began to reject. The brand's ability to manage that volume, consistently and at speed, became the determining factor in whether patients stayed on therapy.
What made this harder was uneven capacity at the point of care. Provider offices, already stretched thin, were being asked to manage a higher volume of more complex prior auth requests. Without systematic support for initiation, routing, and follow-up, the requests stalled. The downstream result looked like patient abandonment or switching, even when the prescriber's clinical intent had not changed.
Working with CoverMyMeds, the brand focused on building execution strength inside the existing provider workflow. Embedding these steps resulted in enabling more consistent routing of submissions to plan review.
For mature brands, prior auth becomes a chronic constraint
Later in the lifecycle, the pressure is less acute but more persistent. As therapeutic classes mature, criteria become more defined, new entrants increase competition and utilization management expands. Prior auth requests grow more frequent and detailed. Each additional requirement is another point where a request can stall.
This is the situation we encountered with another brand. As health plan restrictions changed incrementally over time, approval rates declined significantly. This shift was less visible than a formulary change, but equally damaging to the brand's performance. By the time it registered in prescription data, the gap between submissions and approvals had widened considerably.
Closing that gap required improving how prior auth was executed across the full requesting population, not just the straightforward cases. Providing consistent support for initiation, submission, and follow-up brought more requests through to plan review, and supported patient access to prescribed therapies.
Prior auth is where access strategies are tested
Both scenarios point to the same conclusion. Prior auth is the operational test of whether an access strategy holds under real market conditions.
For biopharma teams, that shifts what success looks like. Coverage and reach matter, but they don't tell you whether requests are moving from initiation to decision efficiently, or whether providers are navigating that process without added work. Brands with visibility across the full prior auth workflow are better positioned to identify where pathways break down and act before the impact reaches prescription data.
This shift also means also means building for volume and variation as markets and criteria change. Medication access performance requires a prior auth infrastructure that can absorb those shifts without depending on manual intervention.
What this means for biopharma planning
Access and affordability pressure tends to build gradually and break suddenly. Addressing it requires treating prior auth requirements as a core access function, one that scales with market dynamics and integrates with how care is delivered.
CoverMyMeds brings the full range of access and affordability capabilities to that work. Our solutions connect the moments that matter across the access journey, from prior auth initiation and affordability support to claims disruption and beyond. For teams that need sharper visibility into where requests are breaking down, a denial analysis identifies frequent denial reasons and the access barriers driving them, so brands can address root causes rather than respond to outcomes. For field teams carrying access conversations into provider offices, a purpose-built data tool delivers prior auth visibility that supports more informed and productive discussions at the point of care.
The brands that build for better prior auth execution now will be better positioned for whatever the market brings next. Explore how biopharma teams are strengthening access through prior auth execution across formulary disruption and late lifecycle pressure.
To learn about our prior authorization technology solution, download our case study:
From Decline to Growth: How One Brand Expanded Access in Late Lifecycle.
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