Prior Authorization: Why It Delays Prescriptions and What to Do
By BetterBuyRx Editorial Team
Written for cost and savings education only — not medical advice, and not medically reviewed. Always confirm details with your doctor or pharmacist. See our methodology.
Last updated
Prior authorization is a rule that requires your doctor to get your health plan's approval before the plan will pay for certain prescriptions. Insurers use it to check that a drug is medically necessary and appropriate under the plan's coverage rules before paying for it (HealthCare.gov). Until that approval comes through, a pharmacy usually cannot bill your insurance for the drug, which is why fills get delayed. Comparing prescription prices can help you find a stopgap cash option while you wait.
Why insurers require prior authorization
Health plans use prior authorization mainly for drugs that are expensive, have a higher risk of misuse, or have cheaper alternatives that the plan wants tried or considered first. The federal government runs its own prior authorization and pre-claim review programs for parts of Medicare to check that services meet coverage rules before payment is made (CMS). Commercial insurers use a similar process, run by the plan or its pharmacy benefit manager, for many high-cost or specialty drugs.
From the insurer's perspective, prior authorization is a way to manage costs and verify appropriate use. From a patient's perspective, it often means an unexpected wait at the pharmacy counter when a new prescription does not go through.
How the process typically works
- Your doctor prescribes a medication that requires prior authorization. The pharmacy system flags this when you try to fill it.
- Your doctor's office submits a request to your insurance plan, usually including your diagnosis, prior treatments tried, and why this specific drug is needed.
- The plan reviews the request against its clinical criteria. This can take anywhere from a day to two weeks, depending on the plan and whether the request is marked urgent.
- The plan approves or denies the request. If approved, the pharmacy can then fill the prescription under your normal benefit. If denied, you can appeal through your plan's exceptions process (CMS).
Medicare Part D plans, for example, have set deadlines: a standard coverage determination request typically gets a decision within 72 hours, and an expedited request within 24 hours, though exact timelines can vary by request type. Ask your specific plan for its current deadlines since rules are periodically updated.
What causes the longest delays
| Situation | Typical impact |
|---|---|
| Missing clinical documentation | Request bounced back, adds days |
| New prescription, no prior treatment history on file | More likely to need added justification |
| Drug requires step therapy first | May be denied until you try a preferred drug |
| Urgent/expedited request properly flagged | Often reviewed faster than standard requests |
| Request submitted right before a weekend or holiday | Processing can pause until the next business day |
What to do if your prescription is stuck in prior authorization
- Call your doctor's office to confirm the request was submitted and ask if anything additional is needed. Missing paperwork is one of the most common delay causes.
- Ask if your situation qualifies for an expedited review. Plans generally must move faster if a delay could seriously harm your health.
- Ask your pharmacist about a bridge option. Some pharmacies can provide an emergency short-term supply in limited situations, and it is always worth asking about the cash price as a temporary option while you wait.
- Track deadlines. If the plan misses its own response deadline, that can support an appeal.
- File an appeal if denied. You have the right to ask your plan to reconsider, and in many cases you can request an external review after internal appeals are exhausted (HealthCare.gov). See our guide on what to do when insurance denies your medication for a full walkthrough.
Search your medication on BetterBuyRx to compare cash prices at nearby pharmacies while a prior authorization request is pending.
Prior authorization versus step therapy
These two utilization management tools often get confused. Prior authorization means your doctor must justify a drug to the plan before it is covered, regardless of what else you've tried. Step therapy specifically requires you to try one or more lower-cost drugs first, and only after those do not work does the plan cover the originally prescribed drug. Step therapy is technically a form of prior authorization, but it has its own trigger: failing or being unable to use the "step one" drug. For more detail, see our guide on step therapy.
Why this connects to what you pay
Prior authorization delays are frustrating, but they are also a cost-control tool tied to your plan's formulary and pharmacy benefit manager relationships. Understanding how your plan structures coverage, including formulary tiers, can help you anticipate which drugs are more likely to need this extra step. See our guide on formulary tiers for more on how plans organize covered drugs, and what a PBM is for background on who is actually reviewing these requests behind the scenes.
While you wait for an authorization decision, it's worth checking whether a cash price would get you the medication sooner. BetterBuyRx's pharmacy price comparison tool lets you see nearby options without the wait, though cash payments generally will not count toward your deductible or apply your insurance discount.
Compare prescription prices on BetterBuyRx if you need a short-term option while a prior authorization is being reviewed.
Frequently asked questions
What is prior authorization?
Prior authorization is a requirement from your health plan that your doctor get approval before the plan will cover certain prescriptions or services. Without that approval, the pharmacy may not be able to bill your insurance, leaving you to pay full price until it clears.
How long does prior authorization usually take?
Timelines vary by plan and drug. Standard requests often take about a week, while urgent requests can move faster under some plan rules. CMS has worked to shorten certain Medicare Advantage decision windows. Ask your plan directly for its specific timeline.
What can I do while waiting on a prior authorization?
Ask your doctor's office if they can submit an expedited or urgent request if your condition qualifies. You can also ask your pharmacist about the cash price as a short-term bridge, or ask about a short trial supply while the request is pending.
Who decides whether a prior authorization is approved?
Your health plan or its pharmacy benefit manager reviews the request using its own clinical criteria. Your doctor's office typically submits supporting information. If denied, you have the right to appeal the decision.
Does prior authorization mean my insurance thinks I don't need the drug?
Not necessarily. Prior authorization is a cost and utilization control, not a medical judgment about your specific case. Many prior authorization requests are ultimately approved once the required paperwork is submitted.
Sources
Compare prices & find savings
This guide is for cost and savings education only. It is not medical advice. Talk to your doctor or pharmacist before making any changes to your medications. Prices vary by pharmacy, location, quantity, and eligibility, and they change over time.
Related guides
- Step Therapy: When Insurance Requires You to Try Cheaper Drugs First
Learn how step therapy works, why insurers use it, and how to request an exception if the required first-step drug is not right for you.
- What to Do When Insurance Denies Your Medication
Steps to take when your health plan denies a prescription, including internal appeals, external review, and options while you wait for a decision.
- What Is a PBM? How Pharmacy Benefit Managers Affect Prices
Learn what a pharmacy benefit manager does, how PBMs shape drug prices and formularies, and what the FTC found about their role in the market.