This story appears in the September–October 2026 issue of Dispense Times.
By Mohammed Chammout, PharmD, BCMTMS, Pharmacy Access and Reimbursement Advisor, Dispense Times
Maria has been on a biologic for her rheumatoid arthritis for three years. Same drug, same dose, same prescriber. Her coverage changes in January, and by February her pharmacy is getting a rejection on a medication she has taken without interruption for 36 months. Her prescriber’s office is on hold with the payer. Her pharmacist is fielding her calls. Nobody has the answer she needs.
This is not an edge case. This is Tuesday.
Prior authorization was designed as a clinical checkpoint to ensure high-cost, high-risk therapies are medically necessary before a payer commits to coverage. The intent was reasonable. The execution has become something else entirely.
A System Built for the Well-Resourced
Prior authorization is now nearly universal, used by 96% of plans, with little payer appetite to relax renewal requirements even for lifelong therapies.¹ Virtually every specialty prescription arrives with the possibility of an administrative wall between the prescription and the fill.
Large health systems and specialty pharmacy hubs can absorb that wall. They employ dedicated PA coordinators, maintain payer-specific documentation templates, and have escalation contacts at major insurers — 40% of larger physician practices have staff who work exclusively on prior authorizations.² Independent pharmacies don’t have that luxury. One pharmacist is often managing a full dispensing queue, counseling patients, and running point-of-care testing, all while trying to navigate a PA denial with no dedicated coordinator and no institutional memory of what Aetna requires for dupilumab versus what BCBS wants for adalimumab.
That’s a structural disadvantage, and it compounds daily.
The Numbers Behind the Friction
The scale isn’t abstract. The AMA’s 2025 Prior Authorization Physician Survey found that 95% of physicians say PA delays access to necessary care, 26% report it has led to a serious adverse event including hospitalization or death, and 79% report that patients abandon treatment because of it.³ Physicians complete an average of 39 PAs a week, spending 13 hours on the process at an estimated annual cost of $34,000 and 700 hours per physician.³
That burden doesn’t stay in the prescriber’s office — it flows downstream. When a PA is incomplete or missing documentation, the rejection lands at the pharmacy counter, not the prescriber’s desk. The pharmacist fields the patient’s call, coordinates back with the office, and often becomes the informal go-between for a payer policy the clinical team may not fully understand. Sixty percent of practices need at least three employees to complete a single PA request, and 35% spend over 35 minutes per request.² For independent pharmacies on compressed margins, the cost of absorbing that coordination informally is real, even if it never shows up on a balance sheet.
Specialty Drugs Make Everything Harder
The burden isn’t evenly distributed. Specialty medications — biologics, immunologics, oncology therapies, rare disease treatments — carry the heaviest PA requirements and the most complex, payer-specific documentation standards. Specialty drugs are projected to exceed 60% of pharmacy spend by 2026 despite accounting for fewer than 5% of prescriptions.¹ Step therapy, clinical exceptions, site-of-care edits, and renewal timelines vary by payer, plan, state, and sometimes formulary tier.
A 2025 analysis at a large specialty cancer pharmacy found over 100 PAs required per week, 1 in 6 prescriptions ultimately denied, and resolution times reaching 35 days.⁴ That was at a well-resourced center with trained staff and well-covered patients. The outcomes at an independent pharmacy serving a less-resourced population aren’t likely to be better, especially with criteria that shift constantly as payers update step therapy rules and formulary tiers mid-year.
Where the Independent Pharmacist Stands
Independent pharmacies sit at a paradoxical intersection. They’re closest to the patient — culturally connected, often bilingual, embedded in communities larger chains don’t serve as well. They know their patients by name and catch documentation gaps a national mail-order operation would never notice.
But that proximity means absorbing the full weight of every access failure. When a PA is denied, the patient doesn’t call the payer — they call their pharmacist. A 2026 Surescripts survey found 51% of prescribers and 47% of pharmacists reported PA denials had increased in the past year.⁵ The administrative load is growing faster than any individual practice or pharmacy can absorb without better tools and better information.
The Information Gap Is the Core Problem
The problem isn’t that prior authorization exists — utilization management, applied appropriately, serves a legitimate function. The problem is asymmetric information. Payers know what their criteria require; prescribers and pharmacists often discover it only after a rejection tells them what was missing.
As one chief medical officer put it in 2025, “The doctor who writes the prescription often doesn’t know if a prior authorization is required, what information the payer needs, or the status of the request.”⁶ If well-resourced practices face that gap, independent pharmacies — often filling in behind a prescriber’s team — face it with far fewer resources to close it.
Knowing upfront what a specific payer requires for a specific drug and a specific patient’s coverage changes the dynamic entirely: it turns a reactive process (submit, get rejected, appeal, resubmit) into a proactive one. Documentation is complete the first time, time to therapy shortens, staff time is protected, and the patient gets their medication. That kind of real-time, payer-specific information is the piece the independent pharmacy ecosystem has been missing — and the piece that changes outcomes when it’s present.
What Comes Next
The legislative environment is moving. Several states have implemented gold card programs exempting high-approval-rate clinicians from repetitive PA requirements, and the CMS-0057-F Final Rule signals a move toward electronic prior authorization through FHIR-based APIs and standardized data exchange.⁷ But policy change takes time, and independent pharmacies are navigating today’s system with today’s tools. The gap between what payers require and what prescribers and pharmacists know upfront is operational, not theoretical.
Closing it doesn’t require a legislative fix. It requires better information, delivered before the prescription is submitted — not after the rejection arrives. That’s where the opportunity is. For independent pharmacists already serving as the de facto access coordinator for their patients, it’s overdue.
Mohammed Chammout, PharmD, BCMTMS is a clinical pharmacist and Pharmacy Access and Reimbursement Advisor to the Dispense Times Editorial Advisory Board. He writes on specialty drug access, PBM policy, and prior authorization strategy. His work has appeared in Pharmacy Times and The Guardian.
References: 1. Drug Topics. Specialty Drug Costs and Complexity Steadily Rising Since 2025. 2026. 2. Rural Health and Pharmacy Access. Pharmacy Prior Authorization in Rural and Pharmacy Deserts in 2026. March 4, 2026. 3. American Medical Association. 2025 Prior Authorization Physician Survey. May 2026. 4. Syed S, et al. Modern landscape of prior authorization burden at a specialty cancer pharmacy. JCO Oncology Practice. 2025;21:177. 5. Surescripts. Data Brief: Healthcare Professionals Highlight Medication Prior Authorization Challenges and Solutions. May 2026. 6. DrFirst. Visibility Ahead: How 2026 Will Defog the Prior Authorization Process. January 2, 2026. 7. Pharmacy Times. The Friction of Care: Why Prior Authorization Reform Must Work at the Pharmacy Counter. July 2026.
