Prior authorization explained — fighting insurance denials for medications
This article provides information about prior authorization and insurance appeals. Always work with your elder's doctor and pharmacist to appeal insurance denials. Never delay or skip medications while appeals are pending without discussing this with your healthcare team.
Your mother's doctor prescribed a medication that's supposed to help her arthritis. It's newer, more expensive than the older medications, but research shows it works better for her specific situation. Her insurance says no. They won't cover it. Instead, they're requiring prior authorization and suggesting she try cheaper medications first. Now there's an argument happening between your mother's doctor and her insurance company about what medicine she should take.
This is prior authorization, one of the most frustrating aspects of modern healthcare. Before paying for certain medications, insurance companies require the doctor to prove that the medication is medically necessary. For some medications, they require documentation that cheaper alternatives have been tried first. The process is meant to control costs. It also delays treatment, creates administrative burden, and sometimes denies access to medications that patients genuinely need.
Understanding prior authorization isn't fun, but it's necessary. When a prescription is submitted and the insurance company requests prior authorization, it means they want more information before they'll agree to pay. This isn't a denial. It's a request for justification.
The most common reason for prior authorization requests is cost. A newer, more expensive medication requires prior auth, while its generic predecessor doesn't. An insurance company might be willing to pay for a medication but wants to know it's truly necessary before committing to the expense.
Another reason is step therapy, sometimes called fail-first. The insurance company requires that your elder try a cheaper medication first. Only if that medication fails can they move to the more expensive option. This makes some sense financially, but it means your elder might spend months on an ineffective medication while jumping through bureaucratic hoops to access what their doctor actually prescribed.
The prior authorization process starts with the doctor. When the insurance denies a claim or requests prior authorization, the doctor receives notification. The doctor's office is responsible for submitting documentation to justify the medication. This might include medical records, lab results, documentation of previous failed treatments, or a letter explaining why this specific medication is necessary.
The timeline matters. Prior authorization can take days to weeks. During this time, your elder is without the medication. This is where it becomes urgent. Your role is to follow up. Ask your elder's doctor about the status. Ask the pharmacy whether prior authorization has been received. Ask the insurance company what information they need. Speed matters.
Some insurance decisions you can push back on. If the insurance company denies a medication saying it's not covered, the doctor can appeal. If they deny because they want step therapy and your elder's doctor disagrees that stepping therapy is appropriate, the doctor can argue this. The insurance company didn't get the last word. The doctor does, and you can support the doctor in making that argument.
Appealing a denial means providing more information. Maybe the doctor provides copies of relevant studies showing why this medication is better for your elder's specific condition. Maybe the doctor documents how previous treatments failed. Maybe the doctor explains that your elder has had adverse reactions to the cheaper medications insurance wants them to try. This information can convince the insurance company to approve the medication.
The process requires persistence. Sometimes the initial appeal is denied. Some insurance companies allow multiple levels of appeal. Each level might go to different people at the insurance company who review the decision differently. Your elder's doctor's office handles much of this, but you should follow up to ensure it's being done.
Some doctors' offices are better at handling prior authorization than others. Larger offices often have administrative staff dedicated to this. Smaller practices might find it tedious and move slowly. You can help by staying on top of it. Check in every few days. Ask the doctor's office about the status. Let them know this matters.
There's also the question of whether to proceed while waiting for prior authorization. Sometimes your elder needs the medication urgently. They can't wait weeks for insurance paperwork. In that case, they might pay out of pocket while the prior authorization is being processed. If it's later approved, some insurance companies will reimburse what was paid. Some won't. Discuss this with the doctor and pharmacy before committing to out-of-pocket payment.
Pharmacy staff can also help work through this. Pharmacists know the insurance system well. They can often predict whether prior authorization will be granted. They might suggest a generic alternative covered without prior authorization. They can contact the insurance company directly about the status. Building a relationship with your elder's pharmacist and asking for their help is valuable.
The emotion of denials shouldn't be minimized. It feels like an insurance company is overruling your elder's doctor, which is often what's happening. Insurance companies do have legitimate financial responsibilities, but those responsibilities shouldn't prevent someone from accessing necessary treatment. When it feels like they are, it's worth fighting.
Sometimes the insurance denial is actually correct. Maybe there's a well-tested medication that's cheaper and works just as well. Maybe your elder hasn't actually tried cheaper options despite thinking they have. Insurance companies sometimes know things doctors don't. But often they're being overly cautious with someone else's health.
The role you can play is becoming the squeaky wheel. Insurance companies might not respond quickly to a single inquiry. They often respond faster when you call, ask for a status update, and indicate you're paying attention. You might need to call daily during the authorization process. You might need to ask to speak to a supervisor. You might need to escalate beyond initial denials. This is the time to be persistent and even a little pushy.
Some people work with patient advocates or insurance specialists who handle these appeals professionally. Some eldercare agencies have staff who know how to work through insurance issues. If your elder has access to these resources through their employer's retiree benefits or through Medicare programs, using them can save time and stress.
State insurance commissioners sometimes get involved in disputes about medication denials. If the appeals process has been exhausted and you believe the insurance company is acting unreasonably, you can file a complaint with your state's insurance department. This is usually a last resort, but it exists.
Prevention matters too. At the start of each year, when your elder might change insurance plans or when insurance formularies change, ask the doctor which of their key medications might have prior authorization requirements. Plan ahead. Work with the doctor to get prior authorizations in place before they're needed.
Your elder's voice matters in this process. They can call their insurance company and explain how the medication denial is affecting their health. They can ask their doctor to call the insurance company directly. They can express urgency. Sometimes a patient's voice is more persuasive than a doctor's letter.
If your elder's medication is denied by insurance, don't accept the denial immediately. Ask the doctor about appealing. Work with the pharmacy to understand next steps. Follow up frequently on the status of prior authorization requests. Contact your insurance company directly if needed. If denial is upheld and you believe it's incorrect, ask about filing a complaint with your state's insurance department.