Key takeaways:
Prior authorization is required by insurance companies for some medications. This requirement often applies to medications that have less-expensive alternatives available.
The prior authorization process can take anywhere from a couple of days to a few weeks. Once approved, prior authorization lasts for a defined time frame.
You may be able to speed up the prior authorization process by filing an urgent request. If you can’t wait for approval, you may be able to pay up front at your pharmacy and submit a reimbursement claim after approval.
Have you ever walked into the pharmacy and been told that your prescription requires prior authorization? You may have thought, “But my healthcare professional prescribed something for me, and I brought in my prescription — shouldn’t that be enough?” In that moment, it would have been helpful to understand why you couldn’t just pick up your medication.
Here is what you need to know about the prior authorization process and how to get prior authorization for medication.
What is a prior authorization?
Prior authorization is a coverage approval from your insurance company — not your healthcare professional. Insurers use the prior authorization process to determine whether or not they will pay for certain medications.
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Prior authorization requirements don’t apply to prescription medications that are paid for fully out of pocket. These coverage reviews are only required for certain medications billed through insurance. So if you’re uninsured or you pay cash for your medication, you won’t need to worry about getting prior authorization.
What types of medications require prior authorization?
Insurance companies often require prior authorization for the following products:
Brand-name medications that have a generic version available
Medications that are only intended for certain age groups or health conditions
Medications used only for cosmetic reasons
Medications that are not preventive
Medications that are used to treat non-life-threatening conditions
Medications (including those prescribed at higher-than-standard doses) that may have adverse health effects and/or dangerous interactions
Medications that carry a risk of dependence or misuse
Medications that aren’t normally covered, but that have been deemed medically necessary
Many glucagon-like peptide-1 (GLP-1) receptor agonists and similar medications
In many cases, the prior authorization process is used to ensure a medication is appropriate for the situation and cost-effective. If you think you may need to get prior authorization for a medication, contact your insurance plan to confirm.
What should you expect if your medication needs prior authorization?
If your medication requires prior authorization, your pharmacy will notify your prescriber. Your prescriber will then give the necessary information to your insurance company. And your insurer will decide whether or not to cover your medication. You may also be required to do step therapy, which involves trying a lower-cost or preferred medication on the formulary before your prescribed treatment.
Keep in mind: Once approved, prior authorization only lasts for a set period of time. That means, if you keep taking the medication, you will likely need to go through the prior authorization process again at some point in the future.
How long does it take to get prior authorization for a medication?
There’s no set time frame for how long it takes to get prior authorization for a medication.
Many prior authorization requests are processed in 1 to 3 business days. This is especially true for requests that involve standard medications and have properly completed paperwork.
Some insurance companies may take as long as 5 to 7 days to complete the prior authorization process. Urgent requests — like those for medications prescribed for a serious or life-threatening condition — may be reviewed within a day. But for complex or specialty medications, the process can end up taking a few weeks, especially if more information is needed or if a previous request was denied.
Processing times for prior authorization requests can vary for several reasons. Here are some of the most common ones:
Insurance company requirements: Each insurance plan has its own review process and timeline. Some insurers may also ask for more documentation than others.
Response and follow-up time: Delays can happen if your prescriber takes an extended period of time to submit an initial response and/or follow-up with your insurer if there is a coverage denial.
Paperwork issues: Missing or incomplete forms can lead to delays.
Type of medication: Reviews involving high-cost or specialty medications often require extra scrutiny, which can slow things down.
Submission method: Electronic prior authorization reviews are now standard in the U.S. and are typically faster than those done by fax or mail, though some clinics and pharmacies still respond using these older communication methods.
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What can you do if a prior authorization review results in a denial?
Unfortunately, your insurer may deny coverage for your medication. If this happens, you can appeal the decision. If your appeal is not successful, you may be left on the hook for the full out-of-pocket cost of your medication.
How to get prior authorization for medication
Submit an appeal if you believe that the prior authorization process unfairly resulted in a coverage denial. Your appeal is more likely to be successful if your prescriber explains why the medication is medically necessary or if there was a clerical error leading to your coverage denial. One of the best ways to build your appeal case is to get your healthcare professional’s input. Ask them if they have any backup documentation or medical notes that could help you prove you need the medication.
If your appeal is denied, your prescriber may still be able to help you. Consider talking to your prescriber about:
Getting a prescription for higher-dose pills, which you can potentially cut in half to curb costs
Filling a 90-day supply, which can be cheaper than filling three 30-day supplies
Getting free samples
Additionally, if you’re filling a costly, brand-name-only medication, you may be able to save by signing up for a manufacturer copay savings card, enrolling in a patient assistance program, or using a GoodRx coupon. And don’t forget to shop around.
Can you speed up the prior authorization process?
You may be able to speed up the prior authorization process by speaking with your insurer directly. In some cases, you may be able to submit an urgent request for a faster decision.
If you need your medication urgently, some pharmacies may let you purchase your prescription with a credit card and reimburse the charge if coverage is approved within a week. This can be risky, but if you received prior authorization for the same medication in the past, it’s likely you’ll receive it again.
Frequently asked questions
Insurance companies use the prior authorization process to make sure medications are safe, effective, and used appropriately. It’s a way to confirm that treatments are medically necessary and avoid unnecessary costs. In some cases, your insurer may want you to try a lower-cost alternative before covering a brand-name, nonpreferred, and/or specialty product. The prior authorization process can also help prevent misuse or overuse of certain medications. Overall, it’s one of the ways insurers try to balance spending with ensuring enrollees get quality care.
Getting prior authorization can take time because your prescriber has to submit paperwork and your insurance company needs to then review it. This process can take a few days — or even longer, if your insurer asks for more information or doesn’t classify the request as urgent. Delays can also happen when there’s a high volume of requests or when the process isn’t fully electronic. If you need your medication quickly, you or your prescriber can submit an urgent request to help speed things up.
Typically, your pharmacy will reach out to your prescriber directly when prior authorization is needed. You can check with your pharmacy if you are alerted that your prescription is delayed because of a prior authorization requirement. You can also contact your prescriber to ensure their prompt and thorough response.
Insurance companies use the prior authorization process to make sure medications are safe, effective, and used appropriately. It’s a way to confirm that treatments are medically necessary and avoid unnecessary costs. In some cases, your insurer may want you to try a lower-cost alternative before covering a brand-name, nonpreferred, and/or specialty product. The prior authorization process can also help prevent misuse or overuse of certain medications. Overall, it’s one of the ways insurers try to balance spending with ensuring enrollees get quality care.
Getting prior authorization can take time because your prescriber has to submit paperwork and your insurance company needs to then review it. This process can take a few days — or even longer, if your insurer asks for more information or doesn’t classify the request as urgent. Delays can also happen when there’s a high volume of requests or when the process isn’t fully electronic. If you need your medication quickly, you or your prescriber can submit an urgent request to help speed things up.
Typically, your pharmacy will reach out to your prescriber directly when prior authorization is needed. You can check with your pharmacy if you are alerted that your prescription is delayed because of a prior authorization requirement. You can also contact your prescriber to ensure their prompt and thorough response.
The bottom line
Your insurance company may require prior authorization before covering your medication. This coverage review may be done to make sure that the medication is an appropriate treatment and/or the most cost-effective option. There’s no set time frame for how long the prior authorization process takes: The timeline can range from a couple of days to a few weeks.
If coverage is denied, you can appeal the decision. Or you can look for ways to make the medication more affordable, such as using a manufacturer copay savings card, enrolling in a patient assistance program, or applying a GoodRx discount.
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References
Berg, S. (2023). What doctors wish patients knew about prior authorization. American Medical Association.
Centers for Medicare & Medicaid Services. (2024). CMS interoperability and prior authorization final rule CMS-0057-F.
Pawlak, M. (2023). Why do I need a prior authorization for my medication? SafeMedication.
