Sanford Health Plan data show most prior‑authorizations approve but pharmacy denials and GLP‑1 requests drive appeals

Summary

Sanford Health Plan told the Employee Benefits Program Committee that prior authorization requests accounted for about 3% of paid claims in 2024 and were approved most of the time, but pharmacy denials—driven by missing documentation and many requests for GLP‑1 drugs for weight loss—accounted for the bulk of appeals.

Sanford Health Plan presented the results of a calendar‑year 2024 review of prior authorization activity for the PERS uniform group insurance plans, telling the Employee Benefits Program Committee on Oct. 7 that prior authorization requests represented about 3% of total paid claims and that most requests were approved.

“Prior authorization refers to medical services, treatments or medications that require previous approval, prior to being administered or prescribed,” Chief Clinical Officer Julie Smith told the committee, explaining Sanford’s utilization management process. Sanford said licensed clinicians—registered nurses and practicing MDs—complete medical prior authorization reviews; pharmacy reviews are conducted by pharmacists and pharmacy technicians.

Sanford reported 8,378 prior authorization requests during 2024 out of roughly 612,000 paid claims. Of those, about 5,163 were medical (roughly 90% approved, 10% denied) and about 3,215 were pharmacy requests (about 1,352 approved and…

Sanford Health Plan data show most prior‑authorizations approve but pharmacy denials and GLP‑1 requests drive appeals

Summary

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