Insight
Prior authorization is a standard feature of the market. Health plans and PBMs rely on it as a medical management tool, and while reform conversations continue, the process remains a daily reality for providers and brands alike. The challenge isn't the process itself — it's what happens when brands aren't actively involved in it.
When prior authorization processes lack embedded support, they create workflow friction for providers, delay therapy starts and introduce real abandonment risk. Requests stall. Denials go uncontested. Patients, with no visibility into what's happening behind the scenes, lose confidence and sometimes give up.
Ninety-four percent of providers report that prior authorization delays delivery of care.[0]American Medical Association. Health Insurance Denials, Delayed Care & Medication Access: How Prior Authorization Hurts Patients. American Medical Association, 15 July 2024 So for biopharma brands, the question isn’t whether to support the PA process, but whether that support is brand-specific, built directly into the workflows where providers and pharmacies already operate. The brands that navigate this landscape most effectively aren’t managing the process from the outside — they stay in the room, present at every stage of the PA journey, from rejection to pickup.
CoverMyMeds makes this possible through a network — a connected access ecosystem — of 50,000+ pharmacies, 1 million providers, and health plan/PBM connections covering 96% of prescription volume. As a pioneer of electronic prior authorization — with 20+ years of experience and more than 500 million PAs processed — CoverMyMeds brings the expertise and network reach to deliver brand-specific PA support throughout the process.
Picture this: A patient's prescription is rejected at the pharmacy. The pharmacist explains that prior authorization is required. For the patient, the reasons don't matter much — all they know is that the medication they need isn't in their hands, and no one can tell them exactly when it will be.
For brands, that moment of patient uncertainty is a critical vulnerability. Every day of delay increases abandonment risk. Therefore, when a claim is rejected within our connected pharmacy network, a prior authorization can be automatically initiated and routed to the provider. For brands that sponsor this support, that notification arrives without displaying alternative therapies, giving the provider a brand-specific path to complete the request for that brand's therapy.
This matters strategically. When providers receive generic PA prompts, they may respond by switching to a therapy with less coverage friction. When they receive a notification focused solely on your brand, the likelihood of completion increases — and your therapy stays in the conversation. CoverMyMeds’ brand-sponsored prior authorization support keeps your brand front and center at a critical handoff in the access journey.
The brands that navigate the prior authorization landscape most effectively are the ones that stay in the room, present at every stage of the PA journey, from rejection to pickup.
Getting a PA initiated is only the beginning. The real work happens in the provider workflow, and without embedded support, this is where many PA requests stall.
Brand-specific support throughout the provider-side PA process includes in-workflow form fill support that helps providers complete requests accurately, intelligent reminder prompts to keep pending requests moving and strategic intervention on requests that have gone quiet. Requests are submitted electronically through our health plan/PBM connections — faster and more reliably than manual fax-based processes. The result: an average 10-percentage-point increase in submissions to plan.[0]ePA program data A/B test 2022 Fewer requests stall in the provider's inbox before they ever reach a payer determination.
When requests are denied, the journey isn't over. Appeal support gives brands a path to contest denials and pursue coverage for patients who don't have other options. For denied requests receiving appeal initiation and support, one of every three is approved on average.[0]ePA Appeals data, 2023 Denial analysis support goes further, pairing claims data with clinical team review to identify patterns and inform provider outreach strategy, so brands know where to focus appeal efforts. Because this happens within the provider's existing workflow — no separate system, no additional burden — those recovered approvals translate directly into more therapy starts, with less friction and delay for your brand.
For even deeper visibility, brands can equip their field teams with provider-level PA data, giving representatives the context to engage prescribing offices more effectively — in one case study, brands with highly engaged field teams saw an average 5% increase in office submission rates.[0]Field Connect program data, May 2023–Feb 2025, cohort of provider offices added to watchlist by highly engaged FRM users Alternatively, or concurrently, CoverMyMeds' Field Reimbursement outsourcing can be deployed to bring patient-level data visibility directly to reimbursement challenges.
The cumulative effect of brand-specific support across the full PA journey — from initiation through submission, reminders, intervention and appeals — is an observed 14-percentage-point improvement in claim approval rates compared to unsponsored prior authorization.[0]CoverMyMeds data on file, Komodo studies 2024
A PA approval is only valuable if the patient finds out in time to act on it. In many provider workflows, the determination arrives at the office and must then be communicated to the patient, a secondary step that introduces delay and another opportunity for a therapy start to slip.
Sponsoring brands can have the PA determination delivered directly to the patient — an option elected by the provider during the PA process, with patient consent. This removes the office workflow as a communication delay and gets the patient moving toward pickup without waiting for a callback. The result: a 2-day improvement in time-to-pickup for patients notified of an approved prior authorization.[0]PA Notify data for approved prior authorizations, 2024
That same determination notice creates a natural opportunity to connect patients to affordability support. When a savings link is embedded directly within the outcome communication, one in five patients accessed it on average[0]PA Notify data for approved prior authorizations, 2024 — meaning a patient who has just learned their therapy is approved doesn't have to wonder whether they can afford to pick it up. It’s one example of how prior authorization support and copay support work together within our connected access ecosystem — covering gaps neither solution can fill alone.
Embedding a savings link within a direct-to-patient outcome communication illustrates how prior authorization support and copay support can work together within a connected access ecosystem — covering gaps neither solution can fill alone.
The prior authorization journey is rarely linear. A single patient might experience a rejected claim, a stalled PA request, a denied determination and a cost barrier at pickup — all before starting therapy. Each of these moments is a potential exit point. Each is also an opportunity for a brand with embedded support to intervene and keep that patient moving forward.
That kind of presence requires more than a point-in-time intervention. It calls for support embedded in the workflows of pharmacies, providers and health plans/PBMs — with the network reach to step in at whatever stage the process stalls. Brands that build this capability into their access strategy don't just respond to the PA process. They shape it. They stay in the room throughout, from the pharmacy rejection to the patient pickup. And for the moments when prior authorization alone isn't the complete answer — when a patient faces cost barriers at pickup, or when coverage is unlikely and a rejected claim needs to convert to paid — copay support and real-time claim conversion are available within the same ecosystem, giving brands a strategic mix of solutions configured to address whatever access challenge emerges.
That support is also designed to scale. As brand needs evolve across the product lifecycle — from launch through growth and into maturity — the level of PA support can be layered and adjusted to match the coverage landscape, ensuring brands maintain the right presence at every stage.
As a result, these brands convert more approved PAs into actual therapy starts and recover more of the ones that shouldn't have been lost.
