Why some treatments need approval before your plan will pay.
Prior authorization is a requirement from your insurance company that a doctor get approval before certain medications, procedures, or services are covered. It's most common for expensive treatments, certain specialty drugs, and procedures that have lower-cost alternatives the insurer wants tried first.
Insurance companies use prior authorization to confirm that a treatment is medically necessary and appropriate before agreeing to pay for it. While it can feel like an obstacle, it's a standard part of how most health plans manage cost and treatment decisions.
A denied prior authorization isn't necessarily final. Your doctor's office can often provide additional documentation, and most plans have a formal appeals process if you believe a denial was incorrect. Your insurance card or plan documents will have the specific appeals process for your plan.
Asking your doctor's office whether a treatment requires prior authorization before your appointment, and confirming your insurer has received the request, can help avoid surprise delays in starting treatment.
Have more questions? Visit our FAQ page or read the full Coverage Guide.