Prior Authorization: The April Fool’s Day Prank No One Laughs At

1 Apr, 2025 | Jennifer LaCoe PharmD, BCPS | No Comments

Prior Authorization: The April Fool’s Day Prank No One Laughs At

Prior authorizations can feel like a bad April Fool’s Day prank.

When you think you are getting the medication that can help your problem, your insurance has other ideas—prior authorization required. You ask how much and nearly pass out. Now, your doctor is left dealing with paperwork as you wait through the delay with frustration. You wonder if the approval process is just a cruel trick. The only difference? This “prank” isn’t funny. It can impact your health and well-being.

Understanding Prior Authorization (PA): What You Need to Know

If you have ever had a prescription or medical service delayed because it needed “prior authorization,” you are not alone. Prior authorization (PA) is a common process in healthcare. When you and your doctor know you need your medication right away, it can be very frustrating. Understanding how PA works can help you navigate the system more smoothly and ensure you get the care you need without unnecessary delays.

What is Prior Authorization (PA)?

Prior authorization is a requirement of your insurance company. Certain medications, treatments, or medical services must be approved before they are covered. Essentially, you doctor must provide information to your insurance company explaining why a specific treatment is necessary.

Why Do Insurance Companies Require PA?

Insurance companies utilize the prior authorization process to:

Ensure the treatment is medically necessary
Encourage the use of cost-effective alternatives (such as generic drugs)
Prevent unnecessary or potentially harmful treatments
Manage costs and prevent fraud

When is PA Required?

You may need prior authorization for:

Certain prescription medications (especially expensive or brand-name drugs) – think Ozempic®, Trulicity®, Mounjaro® (the new GLP-1 RAs that everyone is raving about!)
Specialist visits or procedures (like MRIs or surgeries) – I had to have one for an MRI on my back.
Medical equipment (such as wheelchairs or oxygen supplies) – I have personally seen this for even the newer continuous glucose monitors (CGMs) for patients not on insulin therapy.

How to Handle a PA Request

If your doctor prescribes a medication or treatment that requires PA, follow these steps:

Your Doctor’s Office Submits a Request – Your healthcare provider will send the necessary paperwork to your insurance company.
Insurance Review – The insurance company evaluates the request. This may take days or weeks.
Approval or Denial – If approved, you can proceed with the treatment. If denied, you have the right to appeal.

What to Do If Your PA is Denied

If your PA request is denied:

Ask your doctor about alternatives: A different medication or treatment might be covered.
Request an appeal: You or your doctor can challenge the decision with additional medical justification.
Check Medicare or other insurance options: Some plans have different PA requirements. Sometimes, your insurance may require a process called “step therapy.” Step Therapy requires patients to start with a lower-cost or preferred medication (often a generic or older drug) before “stepping up” to a more expensive or specialized treatment.

Tips for Avoiding PA Delays

Talk to Your Doctor Early – if you know a more expensive medication has been discussed with your doctor, check to see if a PA will be needed. Start the process in advance.
Verify Coverage – Check your insurance plan’s formulary (list of covered drugs) to see if your medication requires PA.
Follow Up with Your Doctor and Insurance – If you do not hear back in a timely manner, call to check the status.
Know Your Rights – If denied, you have the right to an appeal. Medicare beneficiaries can request a faster review for urgent needs.

Some Final Thoughts

Prior authorization can be frustrating. It is an important aspect of how insurance companies manage healthcare costs. By understanding the process and staying proactive, you can avoid unnecessary delays and ensure you receive the medications and treatments you need.

If you’ve had an experience with prior authorization (I shared a few of mine above), share your story or tips in the comments below!