A woman with multiple sclerosis wanted to be able to walk up the stairs at home without losing her balance. Her doctor prescribed medicine that helped, but then approval from her insurance plan for the drug expired.<\/p>\n
\u201cWhy 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?\u201d<\/em><\/strong><\/p>\n \u2014 Jaclyn Mayo, Lunenburg, Massachusetts<\/strong><\/p>\n 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.<\/p>\n After Mayo didn\u2019t have much luck with diet and exercise, her physician prescribed Zepbound, a GLP-1 weight loss medication that suppresses appetite.<\/p>\n \u201cIt was really helping me,\u201d she said. \u201cI could go up and down stairs and not feel like I was going to fall.\u201d<\/p>\n 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.<\/p>\n After being on Zepbound for seven months, she fell into an insurance pitfall: prior authorization.<\/p>\n In August, her pharmacy wouldn\u2019t refill her prescription, and it wasn\u2019t clear why.<\/p>\n She called her pharmacist, then her doctor\u2019s office, the pharmacist again, then her insurance company. After speaking with the insurance company\u2019s pharmacy benefit manager \u2014 a third-party company that oversees prescription drug plans for insurers \u2014 Mayo figured out that the advance approval her insurer had granted for the drug, known as prior authorization, had expired.<\/p>\n Insurers require prior authorizations for certain treatments or tests, especially costly ones. When they do, your doctor has to make the preauthorization 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.<\/p>\n Mayo had been taking the weight loss medicine for less than a year and didn\u2019t 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.<\/p>\n Her doctor submitted the necessary paperwork then found out the new approval would take seven to 10 business days.<\/p>\n 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.<\/p>\n \u201cThat red tape was completely avoidable,\u201d she said. \u201cAnd all that they needed to do was communicate clearly to me. And then I could have continued my medication without delays. But they didn\u2019t.\u201d<\/p>\n Why Insurers Want Prior Authorization<\/strong><\/p>\n Doctors are often frustrated by the prior authorization process, but insurers argue it helps keep costs down.<\/p>\n AHIP, the insurer trade group formerly known as America\u2019s Health Insurance Plans, declined an interview request. But in an emailed statement, it said that prior authorizations are an important safeguard that helps ensure patients receive safe, evidence-based care and keeps coverage affordable.<\/p>\n In a 2024 letter<\/a>, the American Medical Association, which represents physicians, said the way health plans use prior authorizations is \u201copaque and overly complex,\u201d creating delays in care and greater administrative burden.<\/p>\n Patients are also frustrated. A recent poll<\/a> found that 1 in 3 insured adults call prior authorizations a \u201cmajor burden\u201d to accessing health care.<\/p>\n Mayo hit preauthorization hurdles likely because her physician prescribed a GLP-1, an expensive class of medication<\/a>. The more costly the treatment, the greater the scrutiny, said Miranda Yaver<\/a> of the University of Pittsburgh, who studies health politics and administrative burdens within the insurance system.<\/p>\n 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.<\/p>\n \u201cIt\u2019s a solvable problem, if we have the will and the political conditions are ripe. I don\u2019t think that they are at this particular moment,\u201d she said.<\/p>\n Here\u2019s what to know about getting prior authorization requests approved in a timely manner.<\/p>\n 1. <\/strong>Find Out When Your Prior Authorization Expires<\/strong><\/p>\n Individual insurance companies, and even the individual plans within those companies, often have different policies for prior authorizations.<\/p>\n \u201cAs you can imagine, that becomes an absolute nightmare,\u201d said physician David Aizuss, chair of the AMA\u2019s board of trustees.<\/p>\n While expensive treatments are more likely to be targeted for prior authorization review, Aizuss said it also happens for low-cost generic drugs.<\/p>\n 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\u2019s prior authorizations.<\/p>\n 2. <\/strong>Don\u2019t Procrastinate<\/strong><\/p>\n Getting a prior authorization isn\u2019t always quick, so build in time for things to go wrong.<\/p>\n 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.<\/p>\n 3. <\/strong>Ask Your Doctor To Request an Expedited Review<\/strong><\/p>\n 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 PBMs won\u2019t always volunteer that as an option.<\/p>\n When an expedited review is appropriate is up for interpretation, said Kaye Pestaina<\/a>, director of the Program on Patient and Consumer Protections at KFF, a health information nonprofit that includes KFF Health News.<\/p>\n \u201cNo one knows the specifics of what urgent means,\u201d she said.<\/p>\n Federal regulations<\/a> require that urgent requests made by people with employer-based plans be decided within 72 hours. And, on Jan. 1, a federal rule<\/a> took effect that creates a similar requirement for all Medicare Advantage, Medicaid, and Children\u2019s Health Insurance Program plans. However, this rule doesn\u2019t apply to medications.<\/p>\n 4. <\/strong>Consider Other Treatment Options<\/strong><\/p>\n When Mayo\u2019s 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.<\/p>\n Ask your doctor about treatment alternatives. Health plans have different formularies \u2014 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.<\/p>\n But be aware that your insurance company might change your health plan\u2019s drug formulary anytime and require you to get a new prior authorization.<\/p>\n 5. <\/strong>Don\u2019t Be Afraid To Appeal<\/strong><\/p>\n Submit an appeal, even if you\u2019re worried you\u2019ll lose. Yaver said that, based on the research set to be published in her book<\/a>, Coverage Denied: How Health Insurers Drive Inequality in the United States<\/em>, people who appeal a prior authorization or claims denial win about half the time.<\/p>\n First figure out where to send your appeal. Usually, it\u2019s an insurance company, but if the treatment you need is medication, it may be a PBM.<\/p>\n Include detailed records in your appeal.<\/p>\n If you\u2019re trying to get approval for a specific medication, Yaver said, send documentation showing that you tried other medications or treatments that didn\u2019t work. This helps make your case and can speed up the process.<\/p>\n \u201cI actually just went through a prior authorization for my migraine drug,\u201d Yaver said. \u201cIt actually went through very quickly.\u201d<\/p>\n Health Care Helpline helps you navigate the health system hurdles between you and good care. Send us your tricky question and we may tap a policy sleuth to puzzle it out. <\/em>Share your story<\/em><\/a>. The crowdsourced project is a joint production of NPR and KFF Health News.<\/em><\/p>\n\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\nUSE OUR CONTENT<\/h3>\n