Prior Authorization Troubles: How to Get Your Medications Approved | KFF Health News
Jaclyn Mayo of Lunenburg, Massachusetts, found herself in a frustrating situation: after seven months on a medication that significantly improved her multiple sclerosis symptoms, her insurance company informed her that prior authorization had expired. She faced delays in continuing a treatment that helped her walk more steadily and even eased other MS symptoms. Mayo’s experience highlights a growing concern for many Americans – the often-opaque and burdensome process of prior authorizations, which can delay or even deny access to necessary medical care.
Prior authorization requires healthcare providers to obtain approval from an insurance company before prescribing a medication or treatment. Insurers say this process helps control costs and ensures patients receive appropriate care. However, it frequently leads to administrative hurdles, delays in treatment, and increased stress for both patients and physicians. The American Medical Association has criticized the process as overly complex and disruptive to care.
Understanding the Prior Authorization Landscape
The need for prior authorization isn’t limited to expensive or novel treatments. It can apply to generic medications and established therapies, adding to the confusion and frustration. The process varies significantly between insurance plans, making it difficult for patients and providers to navigate. A recent KFF poll found that one in three insured adults consider prior authorizations a “major burden” when accessing healthcare.
The complexity is compounded by the involvement of pharmacy benefit managers (PBMs), third-party companies that manage prescription drug benefits for insurers. Patients often find themselves caught between their doctor’s office, the insurance company, and the PBM, trying to understand the requirements and track the status of their requests. As Mayo discovered, simply understanding why a prior authorization was needed, or had expired, was a significant challenge.
Why the Delays? The Role of Cost Control
Insurers maintain that prior authorization is a crucial tool for managing healthcare costs. By requiring pre-approval, they aim to ensure that treatments are medically necessary and cost-effective. However, critics argue that the process often prioritizes cost savings over patient well-being. The rise in prior authorization requirements coincides with the increasing cost of prescription drugs, particularly newer medications like GLP-1s, which are used for weight loss and diabetes management. These medications, while effective, are often subject to stricter prior authorization criteria due to their higher price tags.
Navigating the System: Practical Steps for Patients
Given the challenges of prior authorization, what can patients do to minimize delays and ensure access to needed care? Several strategies can be helpful:
1. Proactive Inquiry: Know Your Plan’s Rules
The first step is to understand your insurance plan’s specific requirements for prior authorization. Contact your insurer or PBM to find out which medications and treatments require pre-approval and how long the process typically takes. Don’t wait until your prescription is about to run out to start the process.
2. Timely Submission: Don’t Procrastinate
Function with your doctor to submit prior authorization requests well in advance of when the medication is needed. Delays are common, so building in extra time can help prevent interruptions in treatment. Mayo’s experience illustrates the importance of early action; she experienced a two-week gap in medication after her initial request was delayed.
3. Expedited Review: When Urgency Matters
If your health is at risk due to a delay in treatment, ask your doctor to request an expedited review. Federal regulations require insurers to build decisions on expedited requests within 72 hours for employer-based plans, and a new rule effective January 1, 2024, extends this requirement to Medicare Advantage, Medicaid, and CHIP plans. However, this doesn’t apply to medications.
4. Explore Alternatives: Discuss Options with Your Doctor
If prior authorization is proving difficult to obtain for a specific medication, discuss alternative treatment options with your doctor. Your insurance plan may have a more favorable formulary (list of covered drugs) for other medications in the same class.
5. Appeal When Necessary: Don’t Give Up
If your prior authorization request is denied, don’t hesitate to appeal the decision. Research suggests that appeals are successful in about half of cases. Gather supporting documentation, such as letters from your doctor and any relevant medical records, to strengthen your case.
Looking Ahead: Potential Reforms
The challenges with prior authorization have prompted calls for reform. The American Medical Association and other advocacy groups are pushing for greater transparency and standardization of the process. Potential solutions include:
- Standardized forms and criteria: A uniform process across insurers would reduce administrative burden for providers.
- Real-time decision support: Technology that allows providers to check prior authorization status and requirements in real-time.
- Reduced administrative burden: Streamlining the documentation requirements and reducing the number of steps involved in the process.
While these reforms could improve the experience for patients and providers, significant changes will require legislative action and a commitment from insurers to prioritize patient access to care. For now, patients must remain vigilant and proactive in navigating the complexities of prior authorization to ensure they receive the treatments they need.
If you are struggling to navigate a health system hurdle, share your story with KFF Health News.