What Is Prior Authorization and Why Does It Affect My Medication?

If you’ve ever gone to the pharmacy to pick up a prescription and been told, “Your insurance needs prior authorization.” You are not alone.  

This article explains what prior authorization is, why it happens, how it can affect your care, and what you can do if it impacts your medication or treatment. 

Quick Take: 

Prior authorization is an insurance requirement that can delay medications, tests, or treatments, even when your provider believes they’re needed. It means your insurance company must approve the care before they agree to pay for it. This process can take time and is set by insurance plans, not by your provider. At Neighborhood Health Center, our care teams work behind the scenes to submit requests, respond to insurance questions, and advocate for you if delays or denials happen. 

a physician filling out a prior authorization form for a patient

If you’ve ever gone to the pharmacy to pick up a prescription and been told, “Your insurance needs prior authorization.” You are not alone. 

Many patients feel confused, frustrated, or even worried when this happens. You may wonder: 

  • What is prior authorization? 
  • Why does this slow things down? 
  • Did my provider make a mistake? 
  • Will I still be able to get my medication? 

At Neighborhood Health Center (NHC), we hear these questions often. Our goal is to help you understand the process and to reassure you that our care teams are working alongside you every step of the way. 

What Is Prior Authorization? 

Prior authorization (sometimes called preauthorization or prior approval) is a process required by some insurance plans. 

It means your insurance company must approve a medication, test, or treatment before it agrees to pay for it. 

Prior authorization is not required for emergency care. 

Why Do Insurance Companies Use Prior Authorization? 

Insurance companies say they use prior authorization to: 

  • Control costs 
  • Make sure care is “medically necessary” 
  • Encourage the use of lower-cost options 

In practice, this means insurance companies review what your provider ordered and decide whether they will cover it. 

While this process is meant to manage costs, it often creates delays and confusion for patients and providers. 

Related: Understanding Your Health Insurance

a person pouring one pill into their hand from a prescription bottle

What Kinds of Things Might Need Prior Authorization? 

Prior authorization can be required for: 

Medications 

  • Brand-name or specialty medications 
  • Some generic medications 
  • Medications with higher costs 
  • Medications with safety concerns or special instructions 

Tests and Procedures 

  • MRI or CT scans 
  • Planned surgeries 
  • Certain lab tests 

Medical Equipment 

  • Oxygen tanks 
  • Infusion pumps 
  • Other durable medical equipment 

The rules vary by insurance plan. Something that was covered last year (or even last month) may suddenly need prior authorization. 

Who Is Responsible for Prior Authorization? 

Your healthcare provider’s office is responsible for submitting the prior authorization request. 

This includes: 

  • Your medical provider 
  • Nursing staff 
  • Pharmacy staff 
  • Care coordinators 

They must send information to your insurance company explaining: 

  • Why the medication or service is needed 
  • What treatments you’ve already tried 
  • Why alternatives may not work for you 

This process takes time and paperwork and it often happens behind the scenes. 

Related: Learn more about NHC's pharmacy

a pharmacist chatting with a patient about a prescription at the pharmacy

Why Does Prior Authorization Cause Delays? 

Prior authorization can be slow and unpredictable. 

Here’s why: 

  • Insurance companies may take days or weeks to respond 
  • They may ask for more information 
  • Requests are often reviewed by people who are not medical providers 
  • Approval rules can change without notice 

Even when your provider submits everything correctly, the insurance company may still deny the request or delay a decision. 

Does Prior Authorization Mean My Medication Was Denied? 

Not always. 

There are several possible outcomes: 

  • Approved: Your medication or service is covered 
  • Pending: The insurance company is still reviewing it 
  • Denied: The insurance company says no (for now) 

If a request is denied, your provider can often appeal the decision. 

In fact, many prior authorization denials are later overturned. 

Why Are Denials So Common? 

Insurance companies may deny prior authorization if they believe: 

  • A lower-cost option should be tried first 
  • More information is needed 
  • The medication or service doesn’t meet their criteria 

Sometimes, a treatment works well for a patient, but once it improves their condition, the insurance company may say the patient “no longer qualifies.” 

This can be frustrating and confusing, especially when a medication is helping you feel better. 

a woman sitting on a couch, looking at a piece of paper

How Does Prior Authorization Affect Patients? 

Prior authorization can affect patients in many ways, including: 

  • Delays in starting or continuing medication 
  • Missed doses or gaps in treatment 
  • Stress, confusion, and frustration 
  • Worsening health conditions 

Studies show that many patients never pick up medications when prior authorization causes delays. 

At NHC, we know these delays can be harmful. That’s why our teams work hard to move the process forward as quickly as possible. 

What Should I Do If My Medication Needs Prior Authorization? 

If you’re told your medication needs prior authorization: 

  1. Don’t panic. This is common, and it does not mean your provider did anything wrong. 
  1. Let your provider know. Your pharmacy usually sends a notice, but it helps to double-check with your care team. 
  1. Be patient, but stay connected. Prior authorization takes time. Checking in is okay, especially if your symptoms are getting worse. 
  1. Ask about options. Sometimes there may be: 
  • A temporary alternative medication 
  • A lower-cost option 
  • An urgent request if the medication is time-sensitive 
  1. Don’t give up. Your care team can appeal denials and continue advocating for you. 

Why It Sometimes Feels Like No One Is Responding 

It’s understandable to feel frustrated if you’re waiting and haven’t heard anything. 

Often, what’s happening is: 

  • Your provider submitted the request 
  • The insurance company hasn’t responded yet 

This waiting period can feel invisible, but your care team is still working behind the scenes. 

We encourage patients to check in, but we also ask for understanding. This system is frustrating for providers, too. 

frustrated doctor putting his head in his hands while sitting in front of a laptop

Are Doctors and Pharmacists Frustrated Too? 

Yes, very much so. 

Medical providers spend many hours each week completing prior authorization paperwork and appeals. This takes time away from direct patient care. 

At NHC, our providers and pharmacy teams share your frustration. We are committed to fighting for the care our patients need. 

Are There Efforts to Improve Prior Authorization? 

Yes. 

Medical organizations and patient advocates are working to: 

  • Reduce unnecessary prior authorizations 
  • Speed up response times 
  • Increase transparency 
  • Protect patient access to care 

Some states and federal programs are making changes, but progress is slow. 

Until the system improves, our teams will continue advocating for our patients. 

How NHC Supports You 

At NHC, you are not alone. 

We: 

  • Submit and track prior authorization requests 
  • Appeal denials when needed 
  • Look for safe alternatives when available 
  • Communicate with pharmacies and insurance plans 
  • Advocate for timely, appropriate care 

If you have questions about your medication, insurance coverage, or delays, please reach out to your care team. 

a person putting medication into their pill organizer

The Bottom Line 

Prior authorization is an insurance requirement—not a medical decision made by your provider. 

It can be frustrating, slow, and confusing, but it does not mean you don’t deserve care. 

At NHC, we believe: 

  • Your health matters 
  • Your time matters 
  • Your care should not be delayed unnecessarily 

We are here to support you, answer questions, and advocate for your health. 

Prior Authorization: Frequently Asked Questions 

What is prior authorization? 

Prior authorization is when your health insurance company must approve a medication, test, or treatment before they agree to pay for it. Your provider submits this request to the insurance company. Emergency care does not need prior authorization. 

Why does my insurance require prior authorization? 

Insurance companies use prior authorization to control costs and decide what they will cover. They may want to make sure a treatment is medically necessary or see if a lower-cost option is available. This process is set by insurance plans—not by your provider. 

How will I know if my prescription needs prior authorization? 

Most patients don’t know ahead of time if a prescription needs prior authorization. In many cases, patients find out when the pharmacy tries to fill the prescription and sees that insurance approval is required. The pharmacy may tell you directly, or they may notify your provider’s office. Sometimes, your care team will start the process before you even hear about a delay. Because insurance rules change often and vary by plan, providers usually can’t predict this in advance. 

Does prior authorization mean my provider thinks I don’t need the medication? 

No. If your provider prescribed a medication or treatment, they believe it is needed for your care. Prior authorization is an insurance rule, not a medical decision. 

Who submits the prior authorization request? 

Your provider’s office submits the prior authorization request to your insurance company. This may include information about your condition, treatments you’ve tried before, and why the requested care is needed. 

How long does prior authorization take? 

It depends on the insurance plan. Some requests are decided in a few days. Others can take weeks. If your provider believes your situation is urgent, they can request a faster review. 

Why haven’t I heard back yet? 

In many cases, your provider has already submitted the request and is waiting for the insurance company to respond. Insurance companies do not always respond quickly, which can cause delays. You can check in with your care team if you’re concerned. 

What happens if my prior authorization is denied? 

If a request is denied, your provider can often appeal the decision. Many denials are later approved after additional information is submitted. Your care team may also look for safe alternatives if needed. 

Can prior authorization affect medications I’m already taking? 

Yes. Some insurance plans require repeat prior authorization for ongoing medications. Even if a medication is working well, the insurance company may ask your provider to confirm that it is still needed. 

It’s also important to know that approved prior authorizations do not last forever. 

Many insurance plans require prior authorization to be renewed after a set period of time, even if the medication is working well. Reapplication timelines depend on your insurance plan and may happen every 6 or 12 months. 

This means a medication you’ve been taking may suddenly need approval again. When this happens, your care team may need to submit new paperwork to keep your medication covered. 

What should I do if my medication is delayed? 

If your medication is delayed due to prior authorization: 

  • Contact your provider’s office 
  • Let them know what the pharmacy told you 
  • Ask if there are temporary or alternative options 

Do not stop taking a medication unless your provider tells you to. 

Is prior authorization my fault? 

No. Prior authorization is a system created by insurance companies. It can be confusing and frustrating, but it is not caused by anything you did. 

How does Neighborhood Health Center help with prior authorization? 

At NHC, our care teams: 

  • Submit prior authorization requests 
  • Track responses from insurance companies 
  • Appeal denials when appropriate 
  • Work with pharmacies and insurers 
  • Advocate for timely, appropriate care 

If you have questions or concerns, please reach out to your care team. We are here to support you. 

Sources 

a headshot of director of pharmacy michele taneyThis article was reviewed by Michele Taney, PharmD, Director of Pharmacy at Neighborhood Health Center. Dr. Taney earned her Doctor of Pharmacy degree from the University of Connecticut and brings over 20 years of experience in pharmacy care and leadership. She oversees NHC’s pharmacy services, including clinical pharmacy, dispensing services, and 340B operations. Dr. Taney is committed to ensuring patients receive safe, effective, and accessible medication support as part of whole-person care.