A woman with multiple sclerosis wanted to be able to walk up the stairs without losing her balance. Her doctor prescribed medicine that helped, but then insurance approval for the drug expired. "Why do I need a prior authorization for something that I am already prior authorized to take? If my doctor says that they want me on a medication, why does my insurance have another say in that?"
— Jaclyn Mayo, Lunenburg, Massachusetts
Jaclyn Mayo has multiple sclerosis, an autoimmune disease that damages the nervous system and can mess with coordination and balance. To get steadier on her feet, Mayo had been trying to lose weight: A lighter body puts less stress on the joints and leads to greater flexibility.
After Mayo didn't have much luck with diet and exercise, her physician prescribed Zepbound, a GLP-1 obesity medication that suppresses appetite.
"It was really helping me," she said. "I could go up and down stairs and not feel like I was going to fall."
As a happy bonus, the GLP-1 seemed to ease other MS symptoms for Mayo: She started sleeping through the night, and the frequent numbness in her hands went away.
After being on Zepbound for seven months, she fell into an insurance pitfall: prior authorization.
In August, her pharmacy wouldn't refill her prescription, and it wasn't clear why.
She called her pharmacist, then her doctor's office, the pharmacist again, and finally her insurance company. After speaking with the insurance company's pharmacy benefit manager — a third-party company that oversees prescription drug plans for insurers — Mayo figured out that the advance approval her insurer had granted for the drug, known as prior authorization, had expired.
Insurers require prior authorizations for certain treatments or tests, especially costly ones. When they do, your doctor has to make the pre-authorization request to your insurance company, explaining why you need the treatment. Next, the insurer decides if it agrees that the care is medically necessary and if it will pay for it.
Mayo had been taking the medicine for less than a year and didn't understand why a new prior authorization was needed so soon. She said she never got a letter or email notifying her that the clock had run out on her first prior authorization. As someone with a chronic illness, Mayo said, she keeps close track of her medical paperwork. She feels like she did everything right, which, she said, made the situation especially infuriating.
Her doctor submitted the necessary paperwork and then found out the new approval would take seven to 10 business days.
At this point, Mayo had been off her medication for two weeks. Her sleep was getting worse, and the tingling numbness in her hands returned. So she asked that her prior authorization be expedited, only to learn that her doctor, not Mayo, would need to make the request for an urgent review.
"That red tape was completely avoidable," she said. "And all that they needed to do was communicate clearly to me. And then I could have continued my medication without delays. But they didn't."
Why insurers want prior authorization
Doctors are often frustrated by the prior authorization process, but insurers argue it helps keep costs down.
AHIP, the insurer trade group formerly known as America's Health Insurance Plans, declined an interview request. But in an emailed statement, it said that prior authorizations are an important safeguard that help ensure patients receive safe, evidence-based care and keeps coverage affordable.
In a 2024 letter, the American Medical Association, which represents physicians, said the way health plans use prior authorizations is "opaque and overly complex," creating delays in care and greater administrative burden.
Patients are also frustrated. A recent poll found that 1 in 3 insured adults call prior authorizations a "major burden" to accessing health care.
It's likely Mayo hit pre-authorization hurdles because her physician prescribed a GLP-1, an expensive class of medication. The more costly the treatment, the greater the scrutiny, said Miranda Yaver of the University of Pittsburgh, who studies health politics and administrative burdens within the insurance system.
Issues with prior authorizations are common. Policymakers could standardize how insurance companies evaluate prior authorization requests to prevent more Americans from experiencing medical disruptions, Yaver said.
"It's a solvable problem, if we have the will and the political conditions are ripe. I don't think that they are at this particular moment," she said.
Here's what to know about getting prior authorization requests approved in a timely manner.
1. Find out when your prior authorization expires
Individual insurance companies, and even the individual plans within those companies, often have different policies for prior authorizations.
"As you can imagine, that becomes an absolute nightmare," said physician David Aizuss, chair of the AMA's board of trustees.
While expensive treatments are more likely to be targeted for prior authorization review, Aizuss said it also happens for low-cost generic drugs.
To figure out how long your prior authorization lasts, reach out to customer service at your insurance company or pharmacy benefit manager, whichever handles your plan's prior authorizations.
2. Don't procrastinate
Getting a prior authorization isn't always quick, so build in time for things to go wrong.
It took Mayo nearly three weeks to sort out the prior authorization issue for her GLP-1 prescription. She made the initial refill request about a week before her medication was set to run out and ended up without the drug for over two weeks.
3. Ask your doctor to request an expedited review
As you wait for your prior authorization to go through, your doctor might not know how much medication you have left, or that your health may be declining. You can have your doctor request an expedited review. Though, as Mayo found, insurance companies and pharmacy benefit managers won't always volunteer that as an option.
When an expedited review is appropriate is up for interpretation, said Kaye Pestaina, director of the Program on Patient and Consumer Protections at KFF, a health information nonprofit that includes KFF Health News.
"No one knows the specifics of what urgent means," she said.
Federal regulations require that urgent requests made by people with employer-based plans be decided within 72 hours. And, on Jan. 1, a federal rule took effect that creates a similar requirement for all Medicare Advantage, Medicaid, and Children's Health Insurance Program plans. However, this rule doesn't apply to medications.
4. Consider other treatment options
When Mayo's doctor first suggested that she try a GLP-1, approval for the specific medication was taking a long time. When it became clear the request would probably be denied, the doctor canceled that initial request and put in a prior authorization request for a different brand of GLP-1, Zepbound. It was approved.
Ask your doctor about treatment alternatives. Health plans have different formularies — lists of medicines that are routinely approved. It might be easier to switch medications than to fight to get your health plan to approve coverage.
But be aware that your insurance company might change your health plan's drug formulary anytime and require you to get a new prior authorization.
5. Don't be afraid to appeal
Submit an appeal, even if you're worried you'll lose. Yaver said that, based on the research set to be published in her book, Coverage Denied: How Health Insurers Drive Inequality in the United States, people who appeal a prior authorization or claims denial win about half the time.
First, figure out where to send your appeal. Usually, it's an insurance company, but if the treatment you need is medication, it may be a PBM.
And be sure to include detailed records in your appeal.
If you're trying to get approval for a specific medication, Yaver said, send documentation showing that you tried other medications or treatments that didn't work. This helps make your case and can speed up the process.
"I actually just went through a prior authorization for my migraine drug," Yaver said. "It actually went through very quickly."
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