What Is Prior Authorization for Medications?

Prior authorization is a requirement from insurance companies that a healthcare provider obtain approval before prescribing certain medications. This process is intended to control costs and ensure that prescribed drugs are medically necessary, but it can also cause delays in treatment and create extra hurdles for patients and providers.

Why does prior authorization matter?

• Access to necessary medications: Patients may face delays or denials if prior authorization is required for their prescriptions.
• Administrative burden: Doctors and pharmacies must submit documentation proving the necessity of a medication, which can slow down care.
• Medicare considerations: Medicare Part D plans often require prior authorization for high-cost drugs, brand-name medications, or treatments with lower-cost alternatives. Medicare Advantage (Part C) plans may also have strict requirements.
• Appeals process: If a medication is denied, patients have the right to appeal, but the process can be time-consuming and confusing.

How to navigate prior authorization for medications

Patients and caregivers should check their insurance plan’s formulary to see if a medication requires prior authorization. If a request is denied, appealing the decision with supporting medical evidence may help. Some patients may also qualify for exceptions if the prescribed drug is the best or only option for their condition.

How Solace can help

A Solace advocate can help you understand prior authorization requirements, assist in gathering necessary documentation, and work with your doctor’s office to submit requests. If a medication is denied, an advocate can help navigate the appeals process to improve your chances of approval.

What to do next

Struggling with prior authorization delays? Find an advocate today.