Prior authorization: what it is and what to do

Your drug may require prior authorization (PA). Here’s what that means, what to ask your doctor, and what to do if you’re denied. Most people don’t know they can appeal—you can.

• What is prior authorization?

  Prior authorization (PA) is when your insurance company requires your doctor to get approval before they’ll cover a certain drug. Until the insurer says “yes,” the drug may not be covered—or you might pay full price. Many people don’t know PA exists until they’re told their prescription isn’t covered.

• Why do insurers require it?

  Plans use PA to control costs and encourage use of preferred drugs. They may want you to try a cheaper or “preferred” drug first (step therapy), or they need to confirm the drug is medically necessary for your situation. It’s a rule of the plan, not a judgment on whether the drug works.

• What to ask your doctor

  Ask: “Does my insurance require prior authorization for this medication?” If yes: “Can you submit the PA?” and “How long does it usually take?” Also ask: “Is there a generic or another option that doesn’t need PA?” Sometimes switching to a similar drug can avoid the process. Your doctor’s office often handles the paperwork; you may need to sign a form or provide records.

• If you’re denied

  You have the right to appeal. Get the denial in writing (letter or portal) and note the reason and deadline. Your plan’s member handbook or website explains how to file an internal appeal. If you lose the internal appeal, you may have a right to an external review—an independent reviewer (often through your state) looks at the case. Deadlines matter; don’t wait.

• What to do while you wait (or if you appeal)

  Check whether the drug manufacturer offers a copay card or patient assistance program—they can lower out-of-pocket cost or provide medication while PA or appeal is pending. Compare cash prices (e.g. with GoodRx or CostPlus) so you know the cost if you pay out of pocket. Ask your doctor if a short supply or sample is possible during the wait.

• Quick tips

  Request a “peer-to-peer” if the first denial is from a non-doctor reviewer—your doctor can sometimes speak directly to the plan’s medical reviewer. Keep copies of every form, letter, and denial. If your plan has a patient advocate or case manager, use them. Many states have insurance departments that can help with appeals and timelines.