The ‘Prior Auth’ Playbook for Ulcerative Colitis: Cutting Through the Red Tape

"Originally, prior authorization was set up by insurance companies to make sure that people weren't being prescribed medications that were inappropriate for their conditions. It was a way to protect patients," says Stephen Amann, MD, a gastroenterologist at Digestive Health Specialists in Tupelo, Mississippi. "But it has turned into an obstruction to care for many people, and often leads to treatment delays that can have serious ramifications for disease progression."

Prior authorization is a difficult process, but not insurmountable, he adds. If you have UC and you’re in the midst of a "prior auth" situation, here's what you need to know.

While the need for prior authorization can affect you getting diagnostic and monitoring procedures, the issue tends to happen most often with high-cost UC medications like biologics and JAK inhibitors, says Laura Wingate, the chief education support and advocacy officer at the Crohn's & Colitis Foundation.

"For UC, these medications can be life-changing, helping patients achieve and maintain remission and prevent complications, but insurers often want detailed clinical justification before agreeing to pay for them," she explains, adding that this process can involve multiple forms, documentation of past treatments, and coordination between the gastroenterologist, the patient, and a specialty pharmacy.

"These policies are a significant factor for ulcerative colitis care," Wingate says. "For example, a plan may insist on older or less targeted medications before allowing access to biologics or targeted synthetic small molecules, even when guidelines support earlier use of advanced therapies for moderate to severe disease."

The Crohn’s & Colitis Foundation has advocated for policies that limit step therapy because the organization suggests it can undermine shared decision-making between patients and providers and delay use of therapies that control bowel inflammation quickly.

Delays caused by prior authorization or step therapy can also worsen anxiety, stress, and feelings of helplessness, which are already common among people living with UC, says Wingate.

"When inflammation goes untreated or undertreated, patients may experience more frequent flares, pain, bleeding, and fatigue, all of which can significantly impair quality of life and functioning at work, school, and in relationships," she explains. "Persistent uncontrolled inflammation can increase the risk of complications and may make it harder to achieve deep, durable remission later on."

The bulk of up-front work for prior authorizations falls on your health provider's staff, but there are some steps you can take to streamline and potentially speed up the process.

"Patients can start by asking their gastroenterology team whether the practice has a biologic coordinator, nurse, or administrative staff member who regularly handles prior authorizations and can track approvals and denials," suggests Wingate.

No matter who may be assisting with the process, you should keep a detailed record of your medication history, including what you've tried, how it worked, and any side effects, because this documentation is often required to justify advanced therapies, she says.

Another avenue for speeding up the approval process is connecting with an independent specialty pharmacy that's experienced with UC medications.

Biologics and many JAK inhibitors used for UC are typically dispensed through specialty pharmacies rather than neighborhood retail pharmacies because they require special handling, monitoring, and support services, according to Wingate.

"This can create barriers such as limited pharmacy choice dictated by insurance networks, shipping and delivery logistics, and potential delays in coordinating refills or infusion appointments," she says.

Establishing a customer relationship at one of these pharmacies can be beneficial because they may be able to assist with prior authorization paperwork, explains Dr. Amann.

"Not all specialty pharmacies offer to help with prior authorizations, but some will be able to provide the type of documentation needed to make the process go faster, so it's worth asking," he says. "These pharmacies may also be able to assist with appeals if a prior authorization leads to a denial by an insurer."

The Crohn's & Colitis Foundation offers a variety of sample letters and templates you can download, and you can try using an AI program to generate ideas. Amann suggests working closely with your doctor's office to try to minimize delays in requests and appeals.

"Both the prior authorization process and an appeal can take an enormous amount of effort and it's common to be frustrated," he says. "But there are resources out there, and experts like biologic coordinators and specialty pharmacies who can offer insight. It's worth the time and energy to fight for what you need for your UC management."

• Prior authorization requires a healthcare provider to obtain approval from your health insurance plan before they can provide certain services or prescribe medications.
• Research suggests that prior authorization can lead to delays in ulcerative colitis treatment, and may increase risk of complications and hospitalization.
• You can work with your doctor's office and specialty pharmacy to try and speed up the authorization process to prevent delays in care.