Prior authorization (PA) is a core component of health care benefit design that requires approval from a health plan before coverage is granted for certain services or medications. Although PA is intended to manage costs and support appropriate utilization, its increasing use has introduced significant friction across the health care ecosystem. Payers continue to view PA as essential for affordability and clinical oversight, whereas patients encounter barriers to access, providers face substantial administrative burden, and researchers have identified inconsistencies between PA requirements and clinical guidelines. A panel session at the ISPOR 2026 Annual Meeting examined trends in PA adoption and their implications for care delivery while exploring opportunities to build consensus around more transparent and standardized approaches.

Since 2017, the use of utilization management tools, including step therapy, prescriber requirements, and subgroup restrictions, has increased substantially. In 2017, 39% of health plans reported using utilization management strategies, compared with 57% in 2025. By 2025, both Medicare Advantage and prescription drug plans applied some form of utilization management to more than one-half of the medications included on their formularies.

A 2023 survey conducted by the Arthritis Foundation found that 43% of patients underwent PA when a medication was prescribed for the first time, and 37% were required to repeat the process annually with each new plan year. For patients with arthritis, inadequate disease control can have broad consequences, including the need for additional medications, progression of joint damage, and fluctuations in body weight.

The panel also highlighted ongoing reform efforts and technological opportunities to support more transparent and standardized PA processes. Areas identified for improvement included establishing clear guardrails and protections regarding response times, providing explicit explanations for coverage denials, and offering straightforward instructions for appeals.

Agentic artificial intelligence (AI) may also play a role in streamlining PA workflows. Interconnected AI agents used by payers and providers could identify a patient's insurance coverage, determine the payer-preferred therapy, evaluate coverage criteria, and identify the appropriate specialty pharmacy. These systems could potentially authorize recommended therapies and coordinate medication dispensing and patient education. However, several barriers to adoption remain, including the need to establish trust between payers and providers, strengthen cybersecurity protections, develop effective governance frameworks, safeguard patient privacy, and address concerns regarding dehumanization of care.

Reference: 
Westrich K, Watkins J, Chambers J, Hyde A. From Debate to Dialogue: Building Consensus on Prior Authorization Reform. Presented at: ISPOR 2026 Annual Meeting; May 17-20, 2026; Philadelphia, PA.