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What is prior authorization?

Prior authorization (also called “preapproval” or “precertification”) is what your health insurance company sometimes requires in order to approve coverage for certain medications or procedures before they are prescribed. It’s essentially your healthcare provider claiming that the care they prescribed is medically necessary.

Why do some medications or procedures require prior authorization?

Health insurance companies have long used prior authorization as a way to control their costs. Without prior authorization, your insurance plan may not pay for your medication, and you would be responsible for the full cost.

How does prior authorization work?

Your healthcare provider will submit a prior authorization to your health insurance company. Then, your insurance provider can either approve the request, deny the request, ask for more information, or recommend a less expensive, but comparable treatment option.

How long does the prior authorization process take?

Currently, prior authorizations are processed within 5 to 10 days. For some medications, it can take up to 30 days. For urgent requests, prior authorizations can be processed within 72 hours.

What happens if my prior authorization request is denied?

Don’t worry, you have options. Sometimes even simple clerical errors can affect a request. So, the first best step is to find out why. Your healthcare provider should be able to help. You and your provider may choose to appeal the decision if you think the denial was not justified.

What steps can I take to help with prior authorization?

In most cases, your healthcare provider can handle the entire prior authorization process, but knowing what to expect can help.

• Ask your healthcare provider if your prescription requires a prior authorization, so they can start the process as soon as possible.
• Your healthcare provider may need you to answer questions depending on what your insurance company needs.
• If your prior authorization is denied, your healthcare provider’s office can help you either file an appeal or find an alternate solution.
• If your prior authorization is approved, you can fill your prescription as usual.
• Once approved, keep a record of your prior authorization. Most plans approve a prior authorization for, typically, 12 months, after which you would require a prior authorization renewal.