What is a prior authorization and how does it work

Prior authorization is a review that some health plans require before deciding whether to cover some medications, treatments or services.

You may also hear it called preauthorization or prior approval.

If prior authorization is required, your doctor or other health care provider sends information explaining why you need the medication. The health plan reviews the request before making a coverage decision.

Many people first encounter prior authorization when filling a prescription. The pharmacy may tell them that additional review is needed before the medication can be covered.

Learn the basics of prior authorization, including why it may be required, who submits requests and how the review process works.

Prior authorization helps health plans review certain medications before deciding whether to cover them.

A medication may require prior authorization to:

• Confirm it is right for the condition being treated
• Support safe medication use
• See if another medication should be tried first
• Make sure it meets the health plan's coverage rules

Not every medication requires prior authorization. Requirements vary by medication and health plan.

The process usually follows four steps.

1. Your doctor prescribes a medication 

Your doctor or other health care provider recommends a treatment based on your medical needs.

2. Your provider sends information 

If prior authorization is required, your provider sends information about why you need the medication.

3. The health plan reviews the request 

The health plan reviews the information and decides whether to cover the medication.

4. You receive a decision 

The request may be approved, denied or sent back for more information.

The amount of time it takes for a prior authorization can vary depending on:

• The medication requested
• The information provided
• Whether more information is needed
• How urgently the medication is needed

Some requests move through the process quickly, while others may require additional review.

Your provider or health plan can help you check the status of a request.

A denial does not always mean you cannot receive treatment.

Depending on the situation, options may include:

• Having your doctor provide more information (usually in a peer-to-peer review)
• Sharing additional context or medical records
• Getting an alternative medication prescribed
• Filing an appeal  

Your provider can help explain the decision and discuss possible next steps.

Yes. Although many people associate prior authorization with prescription medications, it can also apply to other health care services.

Other procedures and treatments that require prior authorization or a preapproval:

• Imaging tests, such as MRI or CT scans
• Certain surgeries or medical procedures
• Planned hospital stays
• Medical equipment, such as wheelchairs or oxygen equipment

Requirements vary by health plan and type of service.