{"id":50112,"date":"2022-03-29T09:30:30","date_gmt":"2022-03-29T13:30:30","guid":{"rendered":"https:\/\/www.singlecare.com\/blog\/?p=50112"},"modified":"2026-03-22T20:06:29","modified_gmt":"2026-03-23T00:06:29","slug":"prior-authorization","status":"publish","type":"post","link":"https:\/\/www.singlecare.com\/blog\/prior-authorization\/","title":{"rendered":"What you need to know about prior authorization"},"content":{"rendered":"

You\u2019ve just finished your visit with your healthcare provider and you need a prescription. You head to the pharmacy to pick it up, thinking you\u2019ll be in-and-out, only to find out that it\u2019s not so straightforward. Your <\/span>health insurance plan<\/span><\/a> requires prior authorization. While it can sound intimidating, getting prior authorization is a common, standard process. Here\u2019s how it works.<\/span><\/p>\n

What is prior authorization?<\/h2>\n

To put it simply, prior authorization is a process in which your health insurance company wants to make sure a particular treatment is medically necessary for you. Also known as prior approval, pre-authorization, or pre-certification\u2014or abbreviated as prior auth or PA by some insurance companies\u2014prior authorization will determine whether a procedure, prescription drug, durable medical equipment, or other product or service will be covered.\u00a0<\/span><\/p>\n

Who is responsible for prior authorization?<\/h2>\n

Most of the time, your healthcare provider is responsible for starting the prior authorization request. Your healthcare provider will then coordinate with the insurance company and provide the reasoning for why a certain treatment is necessary for you. If the prior authorization is approved, then the treatment is covered. If it\u2019s not approved, and there\u2019s no other treatment option available as an alternative, you and your healthcare provider can appeal the decision.\u00a0<\/span><\/p>\n

In most cases, your healthcare provider will start the prior authorization if they are in-network. However, if you are using a healthcare provider that is <\/span>not in your plan\u2019s network<\/span><\/a>, then you may be the one responsible for getting prior authorization. You will have to call your insurance plan directly to find out how to obtain the prior authorization.\u00a0<\/span><\/p>\n

How does prior authorization help me?<\/h2>\n

Although it can be inconvenient, prior authorization is often carried out by your insurance plan due to concerns about safety or cost. For example, your provider may have prescribed you a medication for a condition that it\u2019s not usually prescribed for, or your doctor may have prescribed a high-risk medication that is commonly misused or abused. In many cases, your insurance company will prefer that you try a low-cost alternative, if available. You can think of a prior authorization as a checkpoint in making sure you\u2019re getting the right treatment.\u00a0<\/span><\/p>\n

What are the repercussions of prior authorization for the patient?<\/h2>\n

On the other side, prior authorization can cause unnecessary delays in treatment. According to a survey from the <\/span>American Medical Association (AMA)<\/span><\/a>, almost half of doctors say prior authorizations often delay access to necessary care. A quarter of doctors even say that prior authorizations have led to more hospital visits because of delayed treatments.\u00a0<\/span><\/p>\n

One case report<\/span><\/a> describes an event where the prior authorization process led to a rehospitalization. A patient developed a reaction to a drug, including severe rash and heart problems. Commonly used medications like high-dose steroids were not helping, but a biologic drug often prescribed for arthritis improved the patient\u2019s condition. However, after the patient was discharged from the hospital, the insurance provider denied coverage of the biologic drug and the patient\u2019s condition worsened, requiring another hospital visit.\u00a0<\/span><\/p>\n

While there are negative reports involving this process, a prior authorization request is approved <\/span>more than 80%<\/span><\/a> of the time according to statistics reports.\u00a0\u00a0<\/span><\/p>\n

Drugs that often require prior authorization<\/h2>\n

Drugs that require prior authorization will depend on the <\/span>insurance plan\u2019s formulary<\/span><\/a>. The formulary is a list of preferred drugs that an insurance health plan covers, and it\u2019s divided into tiers. Drugs that are on a higher tier or not on the list usually require prior authorization.<\/span><\/p>\n