What is a prior authorization?

It’s an approval of coverage from your insurance company, not your doctor. Prior authorization is a restriction put in place by insurance companies, so they can decide whether or not they will pay for certain medicines. It doesn’t affect cash payment for prescriptions, and it’s only required on those prescriptions when billed through insurance—so if you’re uninsured or if you decide to pay in cash, you won’t need to worry about getting prior authorization.

What types of prescriptions require prior authorizations?

Insurance companies will most likely require prior authorizations for the following drugs:

• Brand-name drugs that have a generic available.
• Drugs that are intended for certain age groups or conditions only.
• Drugs used only for cosmetic reasons.
• Drugs that are neither preventative nor used to treat non-life-threatening conditions.
• Drugs (including those dosed at higher than standard doses) that may have adverse health effects, possibly dangerous interactions, and/or risks for abuse or misuse.
• Drugs that are not covered by your insurance, but deemed medically necessary by your doctor.

In many cases, prior authorizations are intended to ensure drug use is appropriate and the most cost-effective therapy is being used. If you think your drug may require a prior authorization, call your insurer directly to confirm.

What should I expect if my prescription needs a prior authorization?

If your prescription requires a prior authorization, the pharmacy will notify your healthcare provider, who will provide the necessary information to your insurance company. Your insurer will then decide whether or not to cover your medicine, and you should hear back from your pharmacist about their decision within two days. Remember, if you are approved, a prior authorization only lasts for a set period of time, and you will likely have to re-apply again for future fills.

What can I do if my prior authorization is denied?

Unfortunately, your insurer can deny you prior authorization, and you may be left on the hook for the full out-of-pocket price of your drug.

If you believe that your prior authorization was incorrectly denied, submit an appeal. Appeals are the most successful when your doctor deems your treatment is medically necessary or there was a clerical error leading to your coverage denial. One of the best ways to build your appeal case is to get your doctor’s input. Ask them about any backup documentation or medical notes that could help you prove your prescription is medically necessary.

If that doesn’t work, your doctor may still be able to help you. Some tricks to save include: getting a prescription for a higher-dose pill (which you can cut half to save on cost), filling a 90-day supply (which can be cheaper than a 30-day supply), or getting free samples. Additionally, if you are filling an expensive brand-only medication, look for any discount cards or patient assistance programs that can help you save. And don’t forget to shop around!

Pro Tip: If you need your medication urgently, some pharmacies may let you purchase your prescription with a credit card as you wait for prior authorization and reimburse you if your authorization is approved within a week. While you are taking a risk, if you received prior authorization for the same drug in the past, it’s likely it will be approved again.

For more on coverage restrictions and how to get the medications you need:

• What is Step Therapy? — How to Get Insurance to Pay for Your “Non-Preferred” Drug
• Prescription Quantity Limits: What to Do When Insurance Plans Limit Coverage

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