What types of medical treatments and medications may need prior authorization?
- Medications that may be unsafe when combined with other medications
- Medical treatments that have lower-cost, but equally effective, alternatives available
- Medical treatments and medications that should only be used for certain health conditions
- Medical treatments and medications that are often misused or abused
- Drugs often used for cosmetic purposes
No Surprises Act
The No Surprises Act was enacted in 2020 and goes into effect on January 1, 2022. It provides federal consumer protections against unanticipated out-of-network bills called “surprise bills.”
Surprise bills arise in emergencies when patients typically have little or no say in where they receive care. They also arise in non-emergencies when patients at in-network hospitals or facilities receive care from providers (such as anesthesiologists) who are not in-network and whom the patient did not choose.
The law requires surprise bills must be covered without prior authorization and in-network cost sharing must apply.1
How do I get a prior authorization?
If your health care provider is in-network, they will start the prior authorization process.
If you don’t use a health care provider in your plan’s network, then you are responsible for obtaining the prior authorization. If you don’t obtain it, the treatment or medication might not be covered, or you may need to pay more out of pocket.
Review your plan documents or call the number on your health plan ID card for more information about the treatments, services, and supplies that require prior authorization under your specific plan.
How does the prior authorization process work?
Typically, within 5-10 business days of receiving the prior authorization request, your insurance company will either:
- Approve your request
- Deny your request
- Ask for more information
- Recommend you try an alternative that’s less costly, but equally effective, before your original request is approved
These responses are based on input from clinical pharmacists and medical doctors who review the requests at the health insurance company.
If you’re unhappy with your prior authorization response, you or your health care provider can ask for a review of the decision.
Is prior authorization required in emergency situations?
No, prior authorization is not required if you have an emergency and need medication. However, coverage for emergency medical costs are subject to the terms of your health plan.
Why does my health insurance company need a prior authorization?
The prior authorization process gives your health insurance company a chance to review how necessary a medical treatment or medication may be in treating your condition.
For example, some brand-name medications are very costly. During their review, your health insurance company may decide a generic or another lower-cost alternative may work just as well in treating your medical condition.
How does prior authorization help me?
The prior authorization process can help you:
- Reduce the cost of expensive treatments and prescriptions by first requiring you to try a lower-cost alternative
- Avoid potentially dangerous medication combinations
- Avoid prescribed treatments and medications you may not need or those that could be addictive
Review your plan documents or call the number on your plan ID card for more information about the treatments, services, and supplies that require prior authorization under your specific plan.
