Understanding Prior Authorization

What prior authorization is

Prior authorization is how an insurance plan decides whether a prescribed medication meets its coverage criteria. Plans often ask for it when a medication is new, expensive, or has lower-cost alternatives. Your prescriber’s office sends the plan the information it asks for, such as your diagnosis and what you have tried before.

Why it exists

Insurance plans use prior authorization to:

• Apply their coverage rules: Checking the request against the plan’s criteria for that medication.
• Control costs: Making sure lower-cost options the plan covers have been considered.
• Apply limits: Some plans limit how much of a medication they cover, or review certain medications more closely.

The types you may run into

• Step therapy: Your insurance requires you to try other medications before approving the one prescribed. These alternatives are usually less costly and are considered effective. If they do not work, the request for the original prescription may then be approved.
• Peer-to-peer review: If a request is initially denied, your doctor can ask for a peer-to-peer review, where a clinician from the insurance company speaks directly with your doctor about your case.
• Quantity limits: Your insurance may cover only a specific amount within a certain time frame. If you need more, your doctor may need to justify the increased amount.

How the process runs

• 1. Prescription and request: Your prescriber chooses the medication. If the plan asks for prior authorization, we let your prescriber’s office know what the plan needs, and they submit the request, including your diagnosis, other medications you have tried, and why this one is needed.
• 2. Review: The plan reviews the request against its coverage criteria and approves or denies it.
• 3. Decision: If approved, the plan covers the medication under your plan’s terms. Approval does not always settle what you pay, since your copay depends on your plan. If denied, your prescriber can appeal or consider other options.
• 4. Appeals and follow-up: Your doctor can submit an appeal with additional information. You can also call your insurance to clarify the decision or ask about alternatives.

Common questions

• How long does it take?: Anywhere from a few days to a few weeks, depending on the medication and the insurance company.
• What if it is denied?: Talk with your doctor, who may submit an appeal or recommend an alternative.
• Will I need one every time?: Not necessarily. For chronic conditions, many are approved for a set period and then need renewal.
• Can I speed it up?: Staying in touch with your doctor's office and the pharmacy helps, as does following up promptly with your insurance for any documentation they ask for.

What helps most

• Keep the lines open: Stay in contact with your doctor's office and with us.
• Ask for updates: You are allowed to call your insurance company and ask where things stand.
• Flag it early: If you know a medication may need prior authorization, tell your doctor's office early to minimize delays.