What you need to know about prior authorization

What is prior authorization? | Who is responsible for prior authorization? | Advantages | Disadvantages | Drugs that require prior authorization | Process | How long does it take? | Denials | Patient advocacy

You’ve just finished your visit with your healthcare provider and you need a prescription. You head to the pharmacy to pick it up, thinking you’ll be in-and-out, only to find out that it’s not so straightforward. Your health insurance plan requires prior authorization. While it can sound intimidating, getting prior authorization is a common, standard process. Here’s how it works.

What is prior authorization?

To put it simply, prior authorization is a process in which your health insurance company wants to make sure a particular treatment is medically necessary for you. Also known as prior approval, pre-authorization, or pre-certification—or abbreviated as prior auth or PA by some insurance companies—prior authorization will determine whether a procedure, prescription drug, durable medical equipment, or other product or service will be covered. 

Who is responsible for prior authorization?

Most of the time, your healthcare provider is responsible for starting the prior authorization request. Your healthcare provider will then coordinate with the insurance company and provide the reasoning for why a certain treatment is necessary for you. If the prior authorization is approved, then the treatment is covered. If it’s not approved, and there’s no other treatment option available as an alternative, you and your healthcare provider can appeal the decision. 

In most cases, your healthcare provider will start the prior authorization if they are in-network. However, if you are using a healthcare provider that is not in your plan’s network, then you may be the one responsible for getting prior authorization. You will have to call your insurance plan directly to find out how to obtain the prior authorization. 

How does prior authorization help me?

Although it can be inconvenient, prior authorization is often carried out by your insurance plan due to concerns about safety or cost. For example, your provider may have prescribed you a medication for a condition that it’s not usually prescribed for, or your doctor may have prescribed a high-risk medication that is commonly misused or abused. In many cases, your insurance company will prefer that you try a low-cost alternative, if available. You can think of a prior authorization as a checkpoint in making sure you’re getting the right treatment. 

What are the repercussions of prior authorization for the patient?

On the other side, prior authorization can cause unnecessary delays in treatment. According to a survey from the American Medical Association (AMA), almost half of doctors say prior authorizations often delay access to necessary care. A quarter of doctors even say that prior authorizations have led to more hospital visits because of delayed treatments. 

One case report describes an event where the prior authorization process led to a rehospitalization. A patient developed a reaction to a drug, including severe rash and heart problems. Commonly used medications like high-dose steroids were not helping, but a biologic drug often prescribed for arthritis improved the patient’s condition. However, after the patient was discharged from the hospital, the insurance provider denied coverage of the biologic drug and the patient’s condition worsened, requiring another hospital visit. 

While there are negative reports involving this process, a prior authorization request is approved more than 80% of the time according to statistics reports.  

Drugs that often require prior authorization

Drugs that require prior authorization will depend on the insurance plan’s formulary. The formulary is a list of preferred drugs that an insurance health plan covers, and it’s divided into tiers. Drugs that are on a higher tier or not on the list usually require prior authorization.

• Brand-name drugs that have a generic alternative
• Drugs that are only approved for certain conditions
• Drugs that can cause dangerous side effects
• Drugs that are often misused or abused
• Drugs that can potentially interact with drugs you may already be taking
• Drugs that are used for cosmetic purposes
• Weight-loss drugs, treatments, or procedures
• Non-preventive drugs 

Drugs that are prescribed at higher doses than normal may also require prior authorization. 

Examples of possible drugs that require a prior authorization

Examples of drugs that require prior authorization, according to one insurance company, WEA Trust, include:

• Alprolix (coagulation factor IX), a protein used to manage bleeding episodes in  people with hemophilia B
• Brineura (cerliponase alfa), an enzyme replacement therapy for CLN2 disease, a type of Batten disease
• Cubicin (daptomycin injection), treats complicated bacterial infections of the skin and blood
• Eligard (leuprolide acetate), hormone therapy used to treat advanced prostate cancer
• Fasenra (benralizumab), a monoclonal antibody for the treatment of severe asthma
• Infugem (gemcitabine hydrochloride in 0.9% sodium chloride injection), a chemotherapy drug used to treat ovarian cancer
• Keytruda (pembrolizumab), an immunotherapy drug for several types of cancer
• Mircera (methoxy polyethylene glycol-epoetin beta), a long-acting erythropoiesis-stimulating agent that treats kidney disease
• Ocrevus (ocrelizumab), a monoclonal antibody that treats multiple sclerosis
• Prolia (denosumab), a biologic drug used to treat osteoporosis
• Supprelin LA (histrelin), an implanted gonadotropin releasing hormone (GnRH) that treats early puberty
• Totect (dexrazoxane), a cytoprotective drug used to reduce the risk of heart problems from doxorubicin and certain chemotherapy drugs
• Yutiq (fluocinolone acetonide intravitreal implant), an intravitreal implant that treats chronic noninfectious posterior uveitis
• Zoladex (goserelin implant), a type of hormone therapy that suppresses estrogen production to treat breast cancer and testosterone production to treat prostate cancer

Prior authorization process

The prior authorization process is usually started once your provider prescribes a drug, procedure, or other treatment. The process can start right at the office, clinic, or hospital of a prescribing healthcare provider. In cases involving prescription drugs, however, the pharmacy usually notifies the doctor that prior authorization is required. After being notified, the healthcare provider initiates the process. 

The prior authorization process typically involves communicating with the insurance company and filling out forms that may be specific to that particular insurance company. The insurance company has a team of doctors, pharmacists, or other healthcare providers who review the prior authorization. 

As a patient, you may not be aware of all the communication and steps carried out during the process. Knowing the steps can increase your awareness of the process and keep you in the loop.

1. A doctor or healthcare provider prescribes a drug.
2. The prescription is sent or brought to the pharmacy to be processed.
3. The pharmacy notifies the healthcare provider that prior authorization is required before the drug can be dispensed.
4. The healthcare provider or their staff starts the prior authorization, checking for the requirements of the insurance company, contacting the health insurance plan, or obtaining any specific forms needed to fulfill prior authorization requirements.
5. The healthcare provider sends any prior authorization forms or medical documents to the insurance company.
6. The insurance company reviews the forms and documents, and then approves or denies the prior authorization.
7. If approved, the drug is dispensed from the pharmacy.
8. If denied, the healthcare provider is notified. The healthcare provider can decide to take no action, prescribe a different treatment that is covered by the insurance plan, or submit an appeal to the insurance company. 

If a prior authorization request is approved, the drug or treatment will be covered and you’ll pay your copay or cost-share. If the request is denied, the drug or treatment will not be covered and you’ll have to pay full out-of-pocket costs. 

Retroactive authorization

Some circumstances will allow for a retroactive authorization. In other words, you might receive treatment before a healthcare provider can submit a prior authorization request. For example, your healthcare provider might not have been able to get your insurance information to request prior authorization. Health insurance companies may allow a retroactive authorization within a certain period of time after the treatment was delivered. 

How long does prior authorization take?

After a prior authorization request is submitted by your healthcare provider, the insurance company will start its review process. The time it takes for an insurance company to make a decision can vary. Some insurance companies can take two to three business days while others can take 10 business days or more to make a decision. 

If you’re in urgent need of treatment, most insurance companies allow you to file an urgent request. With an urgent request, insurance companies can review and reach a decision within one or two days. In the meantime, you may have to pay the full price for the treatment or go without treatment until you get an approval or denial. Some plans may offer reimbursement if you’ve paid out-of-pocket costs for the drug while waiting for prior authorization. 

It is recommended that you regularly follow up with your doctor to make sure they send the required forms or documents to the insurance company. Giving your doctor a little nudge may help expedite the process. Your doctor may also have a team of staff members who handle the prior authorization process. It can be a good idea to work well with these staff members to ensure as smooth a process as possible. 

Is prior authorization required in emergency situations?

No, prior authorization is not required in emergency situations. However, coverage for emergency medical services or treatments will be subject to the terms of your health insurance plan. 

What to do if prior authorization is denied

If your request for prior authorization is denied, you may have to pay out of pocket for the full price of the drug. You may end up paying a hefty amount for a high-cost, brand-name medication. Still, you shouldn’t give up without appealing the decision. 

The first thing you should do if prior authorization is denied is to go through the appeals process. If your healthcare team is submitting an appeal, ask them if they need any supporting medical documents to help prove your case. If your healthcare provider can show strong evidence as to why the treatment is a medical necessity, your insurance company may approve the request. 

Sometimes, a prior authorization request is denied because of clerical errors. All clinical documentation sent along with the request should be up to date with your information. Make sure to follow up with your healthcare provider so they have all the right details about your medical condition.

Your doctor may want to prescribe a low-cost alternative if the request is denied. In addition, your insurance company may require you to try other alternatives (also known as step therapy) before they cover a more expensive treatment. Oftentimes, the low-cost alternative is just as effective as the high-cost treatment. 

Ask your doctor to prescribe a 90-day supply or see if they can prescribe a different strength of the medication. In some cases, prior authorization depends on the day’s supply or dosage of the medication. 

Savings options for when your insurance company can’t help you  

If your prior authorization request is still denied and you’ve already tried a low-cost alternative, you can look toward other possible solutions to help you save on your medication.  Ask your healthcare provider if they have free samples of the drug you need. 

You can also see if there are any manufacturer coupons or savings cards that can help you save on the drug without insurance. 

Patient assistance programs may help cover the cost of a drug. Check with different organizations like the Patient Access Network Foundation (PAN) and Rx Outreach to see if they offer financial assistance to pay for your treatment. Contact these organizations for eligibility requirements and enrollment forms. 

Another way to lower costs is to use a prescription discount card. These discount cards are usually free and easily accessible. The SingleCare discount card, for example, is free and allows you to save up to 80% off on prescription medications at participating pharmacies across the United States. You can also compare the prices of your medication across different pharmacies before you buy so you can get the lowest price. 

Know the process and advocate for your health

Every insurance plan is different. It’s important to know the prior authorization process so you can be prepared. If you have pre-existing conditions or rare, chronic illnesses, you should research and find an insurance plan that will cover your needs. If you have an insurance plan that has coverage tailored to your needs, you’ll be less likely to need prior authorization.  

In any case, it’s good to know the prior authorization process. Medicare, Medicaid, and insurance plans usually have the guidelines and processes outlined in their documents or website. Find out how the prior authorization process works with your plan. That way, you can be empowered to be your own health advocate and get the treatment you need. There are also patient advocacy organizations like the Patient Advocate Foundation and the National Patient Advocate Foundation that can help you navigate the healthcare system.