Prior Authorization

What is Prior Authorization?

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

As an individual on your company’s benefit plan, it may be necessary for you to get approval from your insurance carrier before receiving a treatment, getting surgery, or beginning a new medication. This insurer approval is called prior authorization (sometimes called prior approval, precertification or preauthorization), and is a big step towards ensuring your healthcare pursuits are necessary and being obtained cost-effectively.  

Prior authorization:

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

Keep in mind that if your health care provider is in-network, the prior authorization process will likely be started for you. If you obtain your treatment out-of-network, it will be your responsibility to obtain prior authorization.

How Can I Ensure I Have Prior Authorization?

• Call the number on your health plan ID care 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 ensure they have begun the prior authorization process.
• Ask your doctor their estimated time to completion when filling out the necessary paperwork.
• Check in with your doctor (or the pharmacy if regarding a medication) after 7-10 days to ensure prior authorization was granted.