Prior authorization
Also called Preauthorization, prior approval, PA
Prior authorization, also called preauthorization or prior approval, is approval a health plan may require before you get a service or fill a prescription, in order for the plan to cover it. Without it, a plan can decline to pay even for a drug that is on its formulary, the list of drugs it covers.
For drugs, the plan sets its own criteria, and you or your prescriber must show they are met. That often means documenting that the drug is medically necessary, that the diagnosis has been confirmed in a particular way, or that cheaper options were tried first, a related rule called step therapy. Plans may also authorize a drug for some conditions and not others. When a request is refused, you or your prescriber can ask the plan for an exception.
Why it matters after 45
Medicines people start in midlife, notably GLP-1 medications and testosterone, commonly sit behind prior authorization, and some hormone therapy products can too. The criteria differ by plan and change from year to year, which is why coverage can be a yes for one person and a no for another on the same drug, and why it is worth asking a plan for its criteria in writing.
Where it comes up
- Pricing and insurance FAQformularies, prior authorization and how direct-pay care fits alongside insurance
- TRT costwhat insurers typically require before covering testosterone
- Semaglutide costcommercial and Medicare coverage of GLP-1 medications
- Tirzepatide costthe same questions for tirzepatide
- Weight Loss Program Membershipclinical care for people whose own plan covers a branded GLP-1
Related terms
References
- HealthCare.gov. Prior authorization (glossary). U.S. Centers for Medicare & Medicaid Services. https://www.healthcare.gov/glossary/prior-authorization/
- Medicare.gov. Drug plan rules: prior authorization, step therapy and quantity limits. U.S. Centers for Medicare & Medicaid Services. https://www.medicare.gov/health-drug-plans/part-d/what-drug-plans-cover/plan-rules
Definitions here are educational and are not medical advice. They explain what a term means; the pages linked above cover what it means for you, and a clinician reviews your own results. Editorial & medical review policy · All glossary terms