Prior authorization for medication

Prior authorization (PA) is a requirement by your health insurance company that your doctor obtain approval before the insurer will cover a specific medication. The insurer reviews whether the prescribed drug is medically necessary, appropriate for your condition, and aligns with the plan's formulary and coverage criteria.

47 steps across 12 sections

1. Doctor Prescribes Medication

  • The pharmacy alerts you that PA is required when you try to fill the prescription, or
  • Your doctor's office already knows the medication requires PA and initiates the process.

2. Check If PA Is Required

  • Your insurer's formulary Check your plan's drug formulary (list of covered medications) on the insurer's website or app. Medications requiring PA are typically marked with "PA" or "Prior Authorization Required."
  • Call your insurer Call the number on your insurance card and ask if the specific medication (name, dosage, and form) requires PA under your plan.
  • Ask your pharmacist Pharmacists often know which medications commonly require PA for major insurers.
  • Your doctor's office Many practices have staff who check PA requirements before prescribing.

3. Doctor Submits the PA Request

  • Completed PA request form (insurer-specific)
  • Your diagnosis and medical history relevant to the medication
  • Clinical justification explaining why this medication is medically necessary
  • Documentation of any previously tried medications (relevant for step therapy)
  • Supporting lab results, imaging, or specialist reports

4. Insurance Company Reviews

  • Is the diagnosis appropriate for this medication?
  • Have formulary alternatives been tried first (step therapy)?
  • Is the dosage and duration appropriate?
  • Are there any contraindications?

5. Decision and Timeline

  • Standard requests Typically 24-72 hours for a decision, though it can take up to 5-15 business days depending on the insurer and complexity.
  • Medicare Part D Plans must respond within 72 hours for standard requests.
  • Medicaid Timelines vary by state, typically 24 hours to 14 days.
  • Commercial plans Vary by insurer and state law, commonly 5-15 business days.

6. Outcome

  • Approved Your pharmacy is notified and can fill the prescription. Approval is typically valid for a set period (6-12 months) before reauthorization is needed.
  • Denied You receive a written denial with the reason and your appeal rights. See the Appeal Process section below.
  • Request for more information The insurer may request additional clinical documentation from your doctor before making a decision.

7. Internal Appeal (Level 1)

  • Request the denial in writing: Get the specific reason for denial, the clinical criteria used, and your appeal rights.
  • Gather supporting documentation: Work with your doctor to compile medical records, clinical notes, peer-reviewed literature, and treatment guidelines supporting the medication's necessity.
  • Submit the appeal: Follow your insurer's appeal instructions. Include a letter from your doctor explaining why the medication is medically necessary and why alternatives are inappropriate.
  • Timeline: Most insurers must respond to internal appeals within 30 days for non-urgent requests and 72 hours for urgent appeals.
  • Success rate: Studies show that approximately 82% of denied prior authorizations are overturned on appeal when proper documentation is provided.

8. Peer-to-Peer Review

  • What it is A phone conversation between your prescribing doctor and a medical reviewer (physician) employed by or contracted with your insurance company.
  • When it happens Typically after an initial denial, either before or as part of the internal appeal.
  • Effectiveness More than 50% of denials are overturned during peer-to-peer review.
  • Key concern The insurance company's reviewer may not be a specialist in the relevant field. The AMA has advocated for requiring that peer reviewers have expertise in the condition being treated.
  • Tips for your doctor Come prepared with specific clinical data, relevant guidelines, and a clear explanation of why alternatives are unsuitable for your specific case.

9. External Review (Level 2)

  • If the internal appeal is denied, you can request an external review by an independent third-party reviewer not affiliated with your insurer.
  • Federal right Under the ACA, all non-grandfathered plans must offer external review.
  • Timeline External review decisions are typically made within 45 days for standard requests and 72 hours for urgent requests.
  • Cost External reviews are free to the patient.
  • Binding The external reviewer's decision is binding on the insurance company.

10. Additional Options

  • State insurance department complaint File a complaint with your state's department of insurance if you believe the denial is improper.
  • Ombudsman programs Many states offer consumer assistance programs that help navigate appeals.
  • Legal action In rare cases, patients pursue legal remedies, though this is typically a last resort.

11. How It Works

  • Your doctor prescribes Medication A.
  • Your insurer requires you to first try Medication B (typically a generic or lower-tier drug with the same mechanism of action).
  • You must take Medication B for a specified period (often 30-90 days).
  • If Medication B does not work adequately or causes unacceptable side effects, your doctor documents the failure and resubmits the PA for Medication A.

12. Problems with Step Therapy

  • Treatment delays Patients may experience weeks or months of inadequate treatment or worsening symptoms while trying required medications.
  • Medication discontinuation Research shows that prior authorization and step therapy requirements result in medication discontinuation and worse health outcomes.
  • Not clinically appropriate for all patients The "stepped" medication may not be equivalent for your specific condition, genetic profile, or drug interaction profile.

Common Mistakes

  • Assuming PA is not required
  • Not following up
  • Accepting a denial without appealing
  • Not requesting expedited review when warranted
  • Letting PA expire without renewal

Pro Tips

  • Ask your doctor about alternatives upfront
  • Use CoverMyMeds
  • Request a 72-hour emergency supply
  • Keep copies of everything
  • Ask about manufacturer assistance

Sources

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