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Q: How Does Prior Authorization Work?

Asked by Anonymous on October 13, 2017

Erica Block October 13, 2017

Prior authorization requires your physician to get approval from your insurance provider before he or she can prescribe you certain medications or treatments. Without getting this prior approval, your health insurance provider may not cover the cost of your medication (or operation or treatment), and you’ll have to pay for those medical costs out-of-pocket.

There are several reasons why health insurance providers require prior authorization. Most health insurance companies use prior authorization to keep their expenses in check. Before paying for your medicine or care, insurers may require prior authorization in order to make sure:

  • The service or drug you’re requesting is medically necessary;
  • The service or drug you want is the cheapest treatment option available for your condition; and
  • That medical services aren’t being duplicated. This tends to be a concern when multiple specialists are involved in someone’s care and treatment plan.

As a cost-saving tactic, prior authorization for medication can be effective – especially in situations when your physician prescribes an expensive drug when a cheaper alternative exists. Prior authorization is your insurance provider’s way of ensuring you receive cost-effective care.

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