Prior Authorization

What is Prior Authorization?

Prior Authorization is an approval from your health insurer or plan stating that a healthcare service, treatment plan, prescription drug or durable medical equipment is medically necessary.

As a member of your company’s benefit plan, you may need to get approval from your insurance carrier before receiving treatment, undergoing surgery, or starting a new medication. This insurer approval is called prior authorization (sometimes referred to as prior approval, precertification, or preauthorization), and is a key step in ensuring your care is necessary and cost-effective.

Prior authorization:

• Assists in avoiding unnecessary drugs and procedures.
• Can reduce the cost of prescriptions and treatments by identifying lower-cost alternatives.
• Helps avoid potentially dangerous treatment combinations.

Keep in mind that if your healthcare provider is in-network, they will likely initiate the prior authorization process on your behalf. If you receive treatment out-of-network, it is your responsibility to obtain prior authorization.

How Can I Ensure I Have Prior Authorization?

• Call the number on your health plan ID card for more information about treatments, services, medications, and more that require prior authorization under your specific plan.
• If prior authorization may be necessary, contact your doctor to confirm they have started the process.
• Ask your doctor for an estimated completion time for the necessary paperwork.
• Follow up with your doctor (or the pharmacy if regarding a medication) after 7-10 days to confirm that prior authorization has been granted.