Why It’s Time to Rethink Prior Authorization—Especially for Specialty Medications 

The prescription is written. The patient is ready. But before the therapy journey even begins, it hits a wall: prior authorization. 

This is especially true when the prescription is for a specialty medication—a category that’s growing rapidly and becoming a bigger part of care in almost every therapeutic area. In fact, 75% of the 7,000 new drugs currently in development qualify as specialty medications.  

These therapies are often highly effective but accessing them isn’t always straightforward. Coverage may fall under pharmacy, medical, or both types of benefits. And unfortunately, outdated processes—manual paperwork, unclear requirements—are still the norm. The result? Too many patients face delays, confusion, or high costs that prevent them from starting therapy quickly—or at all. 

“Specialty medication growth is through the roof,” said Colin Banas, M.D., M.H.A., Chief Medical Officer at DrFirst, in a recent Health Innovation Matters podcast. “They come with unique challenges—and one of the biggest is prior authorization.” 

Prior Authorization Needs Modernization 

Prior authorization helps manage the use of high-cost medications and align treatment decisions with clinical guidelines and coverage policies. But the process itself often feels anything but efficient. 

In specialties like rheumatology, oncology, dermatology, and endocrinology—where specialty medications are commonly prescribed—approval frequently requires navigating a maze of documentation, payer-specific rules, and back-and-forth calls. For many practices, managing prior authorizations isn’t just a side task. It has become a full-time job. 

“I’ve talked with clinics where two out of every five employees are focused solely on prior authorizations,” Dr. Banas said. “That’s 40% of your staff doing administrative work. It’s unsustainable—and it’s exactly why this space is ripe for automation.” 

Why Speed Matters in Specialty Care 

The medications in question aren’t optional—they’re often essential for managing chronic, progressive, or life-threatening conditions. When prior authorization introduces delays, it doesn’t just frustrate providers. It disrupts care, affects adherence, and adds anxiety for patients who are facing big healthcare challenges. In some cases, delays can even lead to patients walking away from treatment altogether. 

“Many of these therapies are incredibly effective,” said Dr. Banas. “But they only help if the patient can get on them in time—and stay on them.” 

The good news? It is possible to phase out manual processes and transition to an automated approach that accelerates prior authorizations. 

How Prescription Orchestration Streamlines Access to Specialty Meds 

Too often, prescriptions are treated like simple, one-way transactions: the provider sends, the pharmacy receives. But in reality, a complex sequence of steps and checks need to happen as a prescription is being written all the way through the moment it’s filled. When those steps aren’t connected—or worse, still rely on faxes and follow-up calls—they introduce a frustrating back-and-forth that causes unnecessary delays. 

That’s where prescription orchestration comes in.

“There’s a lot that needs to happen between when a provider writes a prescription and when it gets dispensed,” said Dr. Banas. “By building smart logic into that process, it all happens faster and with less effort.” 

An orchestrated system embeds decision support directly into the prescribing workflow. For example, if a medication is likely to require prior authorization, the system can flag it early, trigger the approval process, and begin gathering the right documentation—before the prescription is even transmitted. 

Just as importantly, orchestration can ensure the prescription is routed to the right destination. Many specialty medications aren’t available at the corner pharmacy—and sending a script to the wrong location only delays care further. 

“There are countless times when a provider sends a specialty medication to a local pharmacy, only to have it bounce back because the pharmacy doesn’t carry that drug,” Dr. Banas explained. “That’s time the patient can’t afford to lose.” 

An intelligent orchestration engine can recognize that a medication must be filled by a specialty pharmacy, and automatically route the prescription there—avoiding delays, unnecessary callbacks, and worried patients. It can keep patients informed about the status of prior authorizations and help coordinate the many handoffs involved in the process, improving collaboration between providers, payers, and pharmacies. That means fewer redundant tasks, less friction, and more predictable outcomes. 

“It’s not just about sending a prescription,” Banas said. “It’s about knowing what needs to happen next—and getting ahead of it.” 

The Role of AI in Automating Prior Authorization Workflows 

Artificial intelligence can take orchestration even further—when applied with purpose. 

“AI can help answer questions, pull clinical data, and even complete parts of the prior auth form automatically,” Dr. Banas said.   

In the future, AI could assist with everything from detecting whether a prior authorization is needed to suggesting alternate covered therapies to drafting documentation that meets payer criteria. And because AI can process large volumes of structured and unstructured data quickly, it’s uniquely suited to support the dynamic, complex decisions involved in specialty prescribing. 

Still, Dr. Banas emphasized the importance of using AI responsibly. 

“We’re not taking the human out of the loop,” he said. “We’re giving them better tools to make smart decisions faster. AI shouldn’t replace clinicians. It should support them.”

Listen to the Full Conversation 

To hear more about the evolution of electronic prior authorization, the rise of specialty medications, and the role of orchestration and AI in simplifying clinical workflows, listen to the full episode of Health Innovation Matters.