Prior authorization is a process required by your insurance company before it agrees to cover the cost of some medications. If your request is denied, they will not pay for the drug, which means you may need to explore other ways to save on prescriptions.
Medically reviewed by Jennie Olopaade, PharmD, RPH
Many people don’t know about prior authorization for medication until they arrive at the pharmacy and find out they can’t pick up their prescription or that it will be expensive to do so.
Private and public insurers, including government services like Medicaid, require prior authorization forms to be filled out before they agree to pay for certain medications.
If your prior authorization request is turned down, you can file an appeal directly with your insurance company. You may also want to try out-of-pocket services like drug coupons or discount cards.
What does prior authorization for medications mean?
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Your insurance company might require that your healthcare professional fill out additional forms and provide more information before it covers certain prescriptions. This is referred to as prior authorization for medications.
A healthcare professional may not know whether prior authorization is required by an insurer when they write the prescription. Sometimes, you may discover this requirement only when you go to a pharmacy to pick up your medication.
If prior authorization is already in process, an insurer might allow you to have a short-term supply of the medication until the prior authorization is approved. You might have to specifically request this exception, though.
Your healthcare professional may also be able to switch you to another medication that has the same purpose but is covered by your insurance plan without prior authorization requirements.
If your insurer won’t cover the cost of the medication and your doctor cannot prescribe alternative medications, you can explore savings on the out-of-pocket cost of the drug.
Do all insurance companies require drug prior authorization?
Prior authorization for medications is a common requirement among U.S. private insurance companies. Government insurers such as Medicaid also have this process. This allows them to control how much they spend per insured person on additional costs like expensive medications.
Which type of medication needs prior authorization?
Each insurance company has its own criteria for deciding which prescription medications need prior authorization before covering the cost.
You may be able to see whether a drug needs authorization by looking at your health insurance online account. Your insurance company might also have a list of medications that require prior approval.
In some cases, your health insurance company might explain upfront what types of prescription drugs typically require prior authorization, such as medications that:
have common drug interactions or complications
have available generic versions that don’t cost as much as the brand name
are considered cosmetic, even if you’re using them for a health condition
have been reported in the list of commonly misused medications
have more affordable alternatives with the same proven effects
A wide range of drugs might fall into any of these categories. Advocates at the American Medical Association say the practice of prior authorization has expanded in recent years to cover many medications, even generic versions, when in the past it was used for only new treatments with limited research.
Sometimes, you might find that your medication does not require prior authorization if bought in a specific form, such as tablets. The same drug may need prior authorization when purchased in a different form, though, like a dermal patch.
For instance, Utah Medicaid requires prior authorization for aripiprazole tablets with a sensor (Abilify Mycite), but aripiprazole tablets without the sensor (Abilify) are not on the prior authorization list.
Other examples of drugs that might require prior authorization from some insurers are:
This list is not all-inclusive, and medications that require authorization may differ between insurance plans or companies.
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What happens if my prescription requires prior authorization?
If your prescription requires prior authorization, either you or your pharmacist will have to let your healthcare professional know.
Then, you and your doctor can work together to fill out the prior authorization forms. The forms are typically available on your insurance company’s website, or your healthcare professional will have copies of them.
The forms must be authorized by your prescribing healthcare professional and submitted to the insurance company in order to receive approval.
Once the forms are submitted, the process may take anywhere from 5 business days to 2 weeks. The insurance company might:
approve the request
deny the request
ask for more information
recommend you use a different treatment
If you go through the prior authorization process and it is denied, you can appeal the decision. If it is denied again, you may still get the medication as long as your healthcare professional’s original prescription is still valid. However, your insurance company will not cover the cost of the drug.
Can you expedite the prior authorization process?
Yes. You may submit an “urgent” prior authorization request to your health insurance. This is usually processed more quickly and you should receive a response within 1–3 days in most cases.
How to save on prescription medication if prior authorization is denied
If your health insurance won’t cover the cost of your medication, there are a few ways you may be able to get your medication at a lower out-of-pocket cost:
Ask your pharmacist: Chain drug stores might have loyalty or discount programs, and independent pharmacies might have plans to lower out-of-pocket drug costs.
Work with a social worker at the hospital: A social worker helps meet the needs of people receiving care, including access to medications. They may help you find alternative or more affordable ways to get your prescriptions.
Reach out to the manufacturer: Some drug makers offer discounts directly to people using their medications.
Subscribe to discount cards or get drug coupons: Prescription drug discount cards and coupons often offer significant reductions in the cost of medications by just downloading a link or digital code. You may be able to save up to 80% on your medications when you use these services, at no cost to you.
Consider comparing all the options above to find which ones offer the greatest discounts and the best price for your medications. You may not be able to combine all of these options.
You can also speak with your healthcare professional about other medications you may use that do not require prior authorization.
Summary
Your insurance company might require additional paperwork before covering the cost of your prescription. This is called prior authorization for medications.
Your healthcare professional may have to fill out extensive paperwork, and you may have to wait up to 2 weeks to get approval or denial from the insurer. If the authorization request is denied, you can file an appeal or look for other ways to reduce the costs of your medications, like discount cards and coupons.
