How long does prior authorization take?

Standard PA: up to 72 hours after the prescribing office submits the form. Expedited PA (when delay would harm health): 24 hours. In practice forms often bounce back for missing documentation, extending the real timeline to 1-2 weeks.

What happens if my PA is denied?

You can appeal. Internal appeals have a 60-180 day deadline depending on plan. Appeal success rate is 40-60% when clinical documentation is thorough. If internal appeal fails, request an independent external review.

Can I skip PA by paying cash?

Yes. Paying out-of-pocket with a copay card or via transparent-pricing pharmacies like Cost Plus Drugs bypasses PA. For specialty drugs this is usually not cheaper than insurance + PA — but for some brand-name drugs with cheap generics available through Cost Plus, it can be.

Does Medicare require prior authorization?

Medicare Part D plans can require PA, step therapy, and quantity limits on specific drugs — it varies by plan. Original Medicare (Parts A + B) also uses PA for certain outpatient procedures and Part B-covered drugs. Each plan publishes its PA list in the formulary document.

What is prior authorization and how do I appeal a denial?

Prior authorization — usually shortened to PA — is the insurance company’s approval process for covering a specific drug, procedure, or service. If your prescriber writes for a PA-required drug and the pharmacy runs the claim, the plan will reject it until the prescribing office submits a PA form with clinical justification.

PA exists for three reasons insurers care about: cost control (specialty drugs are expensive), step therapy enforcement (prove you’ve tried cheaper options first), and safety gating (prevent off-label or high-risk prescribing). For patients, it mostly shows up as delay.

How to know if your drug needs PA

Three ways:

Check your plan’s formulary. Every Medicare Part D and commercial plan publishes a formulary PDF listing which drugs require PA, step therapy, or quantity limits. Search for your drug in the formulary and look for the “PA” column.
Ask the pharmacy to run a test claim. A rejection message usually says “PA required” explicitly.
Use our prior-authorization lookup. We index 7,000+ PA rules across Medicare Part D, Medicaid, and commercial payers from the CMS SPUF (Standard Public Use File) and payer formularies.

The submission timeline

Once your prescribing office submits the PA form, plans have 72 hours for standard PA and 24 hours for expedited PA (if the delay would jeopardize health). In practice it often takes longer because the form bounces back for missing documentation. Track it: call your plan’s member services line 48-72 hours after the office says they submitted, and ask for the PA reference number and status.

When PA is denied: the appeal playbook

Roughly 20-30% of PAs are denied initially. The appeal success rate is high — often 40-60% — if you follow the right steps:

Get the denial reason in writing. Plans must send a denial notice with the specific reason (non-formulary, missing documentation, step-therapy failure, etc.). Request this if you haven’t received it.
Reply with a formal appeal. Every plan has a defined internal-appeal process. Deadline is usually 60-180 days from denial. Written appeals beat phone appeals.
Attach clinical documentation. Prior treatments tried and failed, contraindications to alternatives, relevant labs/imaging, and peer-reviewed literature supporting your drug’s use for your diagnosis.
Request a peer-to-peer review. The prescribing physician talks directly to the plan’s medical director. This often resolves ambiguous denials.
If the internal appeal fails, go external. You can request an independent external review (IMR) — a doctor not employed by the plan reviews. For Medicare, this escalates through the Medicare Office of Medicare Hearings and Appeals.

Special case: step therapy

“Step therapy” means your plan wants you to try (and fail on) a cheaper drug before covering the one your doctor prescribed. If you’ve already tried the step-therapy drug and it didn’t work — or caused side effects — document that carefully in the PA form. “Step therapy override” requests are successful when prior-trial documentation is clear.

Special case: non-formulary exception

If your drug isn’t on the formulary at all, you can file a “formulary exception” request. Plans must respond within 72 hours (24 for expedited). Provide clinical justification for why no formulary alternative works for you.

What doesn’t usually work

Emotional appeals (“I can’t afford this”) rarely move PA decisions — they move copay-card and PAP decisions. Keep the PA appeal strictly clinical. File an appeal based on medical necessity; file a separately financial-assistance application to the manufacturer or a charity foundation for the cost.

Your rights

Under the Affordable Care Act and Medicare rules, plans must provide written denial notices, clear appeal timelines, and external-review access. If a plan ignores these, file a complaint with your state insurance commissioner (commercial) or 1-800-MEDICARE (Medicare).