What you need to know about prior authorization

If your prescription requires prior authorization, your prescriber needs approval from your health plan before the drug can be covered. This process—also called preauthorization or precertification—ensures that a drug or service is used correctly and only when medically necessary.

While it’s typically reserved for high-cost or high-risk services,¹ prior authorization is common in many healthcare plans. Nearly all Medicare Advantage members are in plans that require it for some services, and traditional Medicare plans are starting to follow suit.²

How prior authorization protects you

While any delay in getting the care you need can be frustrating, prior authorization is important to ensure your care is safe, effective and cost-efficient. The process helps safeguard you against:

1. Unexpectedly high medical bills—When prior authorization is required for high-cost services like specialty drugs or inpatient hospital stays, it helps you get the right treatment for your condition at an affordable cost.¹
2. Unnecessary or duplicate services—If your doctor accidentally orders the same test or treatment for you twice, the prior authorization process may catch the error, so you don’t pay a second time.³

Why some drugs require prior authorization

Prior authorization is generally required for any prescription not on your health plan’s formulary or drug list. It may also be needed if you’re prescribed a drug that:

1. Has a lower-cost generic or alternative option available
2. Has a quantity limit your prescriber wants to exceed
3. Is dangerous to combine with another drug you’re taking
4. May have serious side effects or requires special monitoring
5. Is a controlled substance and more likely to be abused or misused

For example, one type of prior authorization for high-cost drugs is step therapy or step edits. Under this requirement, you must see if a lower-cost drug works for you before you can “move up a step” to a more expensive option.

Prior authorization is not needed for emergency care

There’s 1 big exception to all prior authorization requirements—emergency care.

In 2022, the No Surprises Act (NSA) established that emergency services must be covered without requiring prior authorization, regardless of whether a healthcare provider or facility is in network. The NSA is intended for people with individual or employer-sponsored health plans, as Medicare and other government plans already have similar protections.

For example, if you’re given medicine while receiving emergency care, that drug must be covered without prior authorization—even if it’s not on your health plan’s formulary.⁴

If you believe you’ve received a medical bill that violates the NSA, you can file a complaint online or call the No Surprises Help Desk hotline at 800-985-3059, 8 a.m. to 8 p.m., Eastern time.

The prior authorization process and timeline

The process involves submitting paperwork to your health plan proving your medicine is medically necessary. You can ask your prescriber to submit the request or do it yourself.

The strongest requests include medical documentation showing why you need the drug, such as doctor’s notes, test results or clinical guidelines. Try to include that information for the best chance of approval.

If you’re a Humana member, you can learn how to submit a prior authorization request here. If you need help, contact the Humana Clinical Pharmacy Review (HCPR) at 800-555-CLIN (2546), Monday to Friday, 8 a.m. to 8 p.m., local time.

It typically takes about 2 business days to receive a decision from your health plan,⁵ but it could take up to 15 days. If you have an urgent health situation, you can ask for your request to be expedited.⁶

Prior authorization denials and appeals

If your prior authorization request is denied, you have about 6 months to submit an appeal. Your health plan is required to respond to an appeal within 30 days.⁶

If your first appeal is denied, you can ask for an external review where an independent third party will make the final decision.⁷ Learn more about the appeal process at Healthcare.gov.

What to do if your appeal is denied

If your drug isn’t approved after the appeal, you can see if your health plan covers alternative treatment. Or you can pay for your drug out of pocket.

Talk to your prescriber about ways to save on drug costs, such as:

1. Asking for a higher dose that you can cut in half
2. Getting a 3-month supply, which may be cheaper than a 1-month supply
3. Checking if the drug manufacturer has a patient assistance program

How CenterWell Pharmacy makes prior authorization easier for you

CenterWell Pharmacy® is here to help you navigate the prior authorization process from start to finish:

1. When a prescription requires prior authorization, we contact your prescriber directly before filling it to make the process easier.
2. If your prior authorization request is approved, we can fill the prescription and mail it to you via convenient home delivery.
3. If your prior authorization request or appeal is denied, we can work with your prescriber to find an alternative treatment option.
4. If you have any questions about the prior authorization process, our Customer Care specialists are happy to help.

Sources

1. Kaye Pestaina and Karen Pollitz, “Examining Prior Authorization in Health Insurance,” Kaiser Family Foundation, last accessed April 24, 2023.
2. Freed et al., “Medicare Advantage in 2022: Premiums, Out-of-Pocket Limits, Cost Sharing, Supplemental Benefits, Prior Authorization, and Star Ratings,” Kaiser Family Foundation, last accessed April 24, 2023.
3. Leigh Poland and Srivalli Harihara, “Claims Denials: A Step-by-Step Approach to Resolution,” AHIMA, last accessed April 24, 2023.
4. Centers for Medicare & Medicaid Services, “No Surprises: Understanding Your Rights Against Surprise Medical Bills,” last accessed April 24, 2023.
5. American Medical Association, “2022 AMA Prior Authorization (PA) Physician Survey,” last accessed April 24, 2023.
6. Healthcare.gov, “Appealing a Health Plan Decision: Internal Review,” last accessed April 24, 2023.
7. Healthcare.gov, “Appealing a Health Plan Decision: External Review,” last accessed April 24, 2023.