Understanding Prior Authorization

Prior authorization is a common part of using health insurance, but it can be inconvenient to many people. A 2026 KFF poll shows about 7 in 10 insured adults see prior authorizations as taxing. Understanding how and when it’s required can help you avoid surprises and get the care you need with less stress.

What Is Prior Authorization?

Prior authorization (also called preauthorization, precertification, or prior approval) is your health plan’s way of confirming that a medication, test, or treatment is appropriate and covered before you receive it. Step therapy is a type of prior authorization that requires trying lower-cost drugs first before moving to more expensive options.

In most cases, the process works like this: your doctor recommends care, submits a request to your insurance, the insurer reviews it against clinical guidelines, and then you and your doctor receive an approval, denial, or request for more information. Urgent requests are usually decided within a few days; non-urgent requests can take longer.

Prior authorization helps manage costs and avoid unnecessary care, but missing or incomplete information can delay treatment.

When Is Prior Authorization Needed?

You may need prior authorization for certain prescription drugs, imaging tests (like MRIs or CT scans), planned surgeries or hospital stays, specialty treatments, or durable medical equipment.

Emergency care is typically exempt, but follow-up care may require approval. Check your benefits documents or your insurer’s drug/procedure list to see what needs prior authorization.

Who Handles the Prior Authorization Process?

In most cases, your health care provider handles the prior authorization, including explaining the medical need and sending any required records.

If you see an out-of-network provider, you may need to contact your insurance carrier directly to help submit the request.

What if a Prior Authorization Is Denied?

A denial doesn’t mean you can’t get the care you need. You and your provider can:

• Send additional information the plan requested
• Appeal and explain why the treatment is medically necessary
• Consider covered alternatives, such as completing step therapy

Appeals are common, and many denials are overturned once detailed medical documentation is submitted.

Why Is Prior Authorization Required?

Prior authorization isn’t designed to block care. Health plans use it to help ensure that:

• The treatment is medically necessary and appropriate for your condition, based on current medical guidelines and evidence. Health plans use clinical experts, such as doctors and pharmacists, to review requests against the latest research and standards.
• Safer, more effective options have been considered, especially for higher‑risk drugs or procedures. Prior authorization confirms that standard or lower‑cost treatments were tried first and that the chosen option is safe and appropriate for you.
• Costs stay manageable for you and the plan by confirming whether a lower‑cost, equally effective option is available. Prior authorization helps steer care to effective, cost‑efficient treatments such as generics instead of brand‑name drugs, supporting more stable overall plan costs and premiums.
• Your care follows your health plan’s coverage rules, helping you avoid unexpected, out‑of‑pocket bills. Prior authorization checks that the services your doctor orders match your plan’s covered treatments, preferred medications, network providers, and benefit requirements.

Conclusion

Prior authorization can feel like an extra step, but it’s there to help ensure your care is safe, effective, and covered under your plan. If you’re unsure whether something needs prior authorization, check your health plan documents or call your insurance company, and reach out to your provider with any questions about the process. Download the bulletin for more details.