What Is Prior Authorization for Medication? A Pharmacist Explains

Prior authorization may also be called preauthorization, prior approval, precertification, or medication authorization. HealthCare.gov describes it as approval that may be required before a patient receives a service or fills a prescription.¹ It is important to understand that receiving prior authorization does not always guarantee what the patient's final cost will be.

Why Do Some Medications Require Prior Authorization?

A health plan may require prior authorization when a medication:

• Has specific FDA-approved uses
• Is expensive
• Has important safety considerations
• Requires specialist supervision
• Has less costly treatment alternatives
• Is commonly prescribed outside the plan's coverage rules
• Has limits on its dose, quantity, or duration of treatment

The purpose of the review is to determine whether the requested medication meets the patient's plan-specific coverage criteria. This does not mean the insurance company is diagnosing the patient or replacing the prescriber. It means the plan is deciding whether the medication qualifies for payment under the patient's pharmacy benefit.

How Does Medication Prior Authorization Work?

The process usually begins when the pharmacy submits the prescription to the insurance plan. If prior authorization is required, the pharmacy receives a message stating that additional approval is needed. The pharmacy then contacts the prescriber, or the prescriber may submit the request electronically.

The prescriber's office may need to provide:

• The patient's diagnosis
• Relevant symptoms or disease severity
• Previous medications tried
• Reasons previous treatments were ineffective or inappropriate
• Laboratory results or test findings
• The requested dose and quantity
• Relevant medical records
• The prescriber's clinical explanation

The insurance plan reviews the information and then approves the request, denies it, or asks for additional documentation.

How Long Does Prior Authorization Take?

The amount of time varies based on the health plan, the type of medication, the information submitted, and whether the request is considered urgent. Some requests are decided quickly when all required information is included. Others take longer because records are missing, questions must be answered, or additional review is needed.

Patients can help reduce delays by confirming that the prescriber's office has:

1. Received the pharmacy's message
2. Submitted the prior-authorization request
3. Included the relevant medical information
4. Responded to any request for additional documentation

CMS continues to promote electronic prior authorization as one way to reduce administrative delays and improve communication among health plans, prescribers, and patients.²

Does Prior Authorization Mean the Medication Was Denied?

No. A prior-authorization requirement is not automatically a denial. It means the plan needs additional information before making a coverage decision. A true denial occurs after the request has been reviewed and the plan determines that the submitted information does not meet its coverage requirements.

What Can You Do When a Medication Requires Prior Authorization?

Start by asking the pharmacy exactly what message it received. Then contact the prescriber's office and let the staff know that the medication requires prior authorization.

You can also call the member-services number on your insurance card and ask:

• Has the request been received?
• Is additional information needed?
• What is the expected review timeframe?
• Is the medication on my formulary?
• Does step therapy apply?
• Is there a covered alternative?
• What are my appeal rights if the request is denied?

Keep a record of the dates, names, reference numbers, and information provided during each call.

What Happens If Prior Authorization Is Denied?

A denial does not always end the process. The prescriber may be able to submit missing information, request reconsideration, recommend a covered alternative, or file an appeal. Depending on the plan and the type of denial, an independent external review may also be available.⁴ Read the denial letter carefully — it should explain why the request was denied and describe the available appeal process.

Frequently Asked Questions