Prior authorization is a health-plan review that may be required before coverage begins for a prescription. The prescriber and plan exchange information, and the plan issues a decision under its current rules.
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The prescriber submits the request and supporting information. The plan reviews it against current criteria and may ask for more information. It then approves, denies, or explains an appeal route. Timing and renewal periods vary by plan and jurisdiction.
Plans may require review for specialty medicines, biologics, some brand products, or medicines with specific coverage criteria. Check the formulary or ask the pharmacist; requirements differ by plan.
Some plans require a trial of another medicine before covering a requested one. If a request is denied, the notice should explain the reason and appeal route. Your prescriber can help submit relevant information; contact the plan for current deadlines.
Ask your pharmacist about a cash price, temporary supply, or assistance program. Do not stop or change a prescribed medicine without speaking with your healthcare professional.
Compare a current cash price while coverage is reviewed.
Compare Prices on RxDiff →What is prior authorization?
It is a plan review required before coverage of some prescriptions. The prescriber submits information and the plan makes a decision under its rules.
How long does it take?
Timing varies by plan, request type, and applicable law. Ask the plan when its response is due.
What is step therapy?
It is a rule that may require trying another medicine before coverage of a requested medicine. Ask about exceptions when appropriate.
What if authorization is denied?
Read the denial notice and follow its appeal instructions. Your prescriber may provide supporting information.
Do GLP-1 medicines require authorization?
Some plans require authorization for some GLP-1 prescriptions. Check your plan's current rules for the medicine and indication.
Can I fill a prescription while waiting?
Ask your pharmacist about a cash price or other temporary options. Discuss any treatment decision with your prescriber.
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