Prior Authorization: What It Is and How to Navigate the Process

When your doctor prescribes a medicine but your insurance says prior authorization, a requirement from your health plan that confirms a medication is medically necessary before they’ll pay for it. Also known as pre-approval, it’s a gatekeeper system that can delay or deny your treatment if you don’t jump through the right hoops. This isn’t about saving money for the insurer—it’s about controlling costs by pushing doctors toward cheaper or older drugs, even if your condition needs something else.

Prior authorization isn’t random. It usually hits you when you’re prescribed a high-cost drug, a brand-name medication when a generic exists, or a treatment that’s not on the insurer’s approved list. You might get hit with this after a hospital stay, for an ADHD med, or even for a common painkiller if it’s been flagged as overused. Your doctor’s office handles the paperwork, but they’re often buried under forms and phone calls. That’s where you come in. If you don’t follow up, your prescription sits in limbo—and your condition gets worse.

Related to this are insurance approval, the formal process where your plan reviews and accepts or rejects a request for coverage, and pharmacy claims, the electronic requests sent from your pharmacy to your insurer to get paid for your meds. If the prior authorization fails, the pharmacy won’t fill it. No matter how urgent your need, no matter how many times your doctor calls, the system won’t budge without that approval number. And if you’re on multiple meds—like for diabetes, high blood pressure, or depression—you might be dealing with five different prior auth requests at once.

Some people get lucky. Their doctor’s office has a staffer dedicated to chasing these approvals. Others? They’re left calling the insurance company, writing letters, and begging for exceptions. The good news? You have rights. Most plans must respond within 72 hours for urgent cases and 30 days for non-urgent ones. If they deny you, you can appeal. And sometimes, just asking for a medical exception—backed by your doctor’s notes—gets it approved.

This isn’t just about getting your pills. It’s about staying on your treatment plan. Miss a dose because your insulin got stuck in prior auth? Your blood sugar spikes. Delay your cancer drug because the paperwork got lost? The disease moves faster. We’ve seen posts here about switching antidepressants, managing opioid pain, and fighting antibiotic resistance—all of which can get derailed by a single denied prior authorization.

In the posts below, you’ll find real stories and practical steps from people who’ve been through this. You’ll learn how to spot when prior authorization is coming, what to ask your doctor before they write the script, how to track the status, and what to say when the insurance rep tells you "no." Some of these guides show how to fight back when your meds are denied. Others break down what’s in the paperwork so you’re not lost in jargon. This isn’t about bureaucracy—it’s about your health. And you deserve to get your meds without playing phone tag for weeks.