What Is a Prior Authorization, And Why Is My Doctor's Office Telling Me to Call the Pharmacy?

What Is Prior Authorization?

Prior authorization, also called pre authorization, pre approval, or PA, is a requirement by your health insurance plan that your prescriber obtain approval from the insurance company before the plan will cover a specific medication.

When your pharmacist runs your prescription through your insurance and it comes back requiring prior authorization, it means the insurance plan has flagged that medication as one that requires documented clinical justification before it will be covered at the plan’s normal cost sharing level.

Until the prior authorization is approved, one of two things happens: the pharmacy cannot dispense the medication at the covered copay, or, in some cases for non urgent medications, the pharmacy can dispense a limited emergency supply while the authorization process proceeds.

Why Do Insurance Plans Require Prior Authorization?

Insurance plans frame prior authorization as a utilization management tool, a mechanism for ensuring that expensive or high risk medications are prescribed appropriately for conditions where they are clinically supported.

The stated rationale is not entirely without merit. For certain medication categories, specialty biologics, high cost brand medications, opioids, some psychiatric medications, there is genuine clinical value in ensuring that a prescribing physician has documented why the specific medication is appropriate before the plan covers it.

The practical reality is more complicated. Prior authorization requirements have expanded dramatically over the past two decades to include medications that are not particularly high risk or high cost, often because requiring authorization creates a barrier that reduces utilization and saves the insurance plan money regardless of whether the medication is clinically appropriate.

The American Medical Association’s annual prior authorization surveys have consistently documented that prior authorization delays and denials cause significant patient harm, patients who abandon prescriptions because the authorization process is too cumbersome, patients who experience disease deterioration while waiting for authorization approval, and patients who end up in emergency rooms for conditions that could have been managed with the prescribed medication if authorization had not delayed access.

The prior authorization process is also a significant burden on physician practices. The average physician’s office spends approximately 14 hours per week per physician dealing with prior authorization requirements, time that is not spent caring for patients.

Who Is Responsible for Getting Prior Authorization?

This is the question that generates the most confusion, and the most phone calls between patients, physician offices, and pharmacies.

The prescribing physician’s office is responsible for submitting the prior authorization request. The insurance plan requires documentation of medical necessity from the prescriber. The pharmacy cannot submit that documentation because the clinical rationale is the physician’s, not the pharmacist’s, responsibility.

The pharmacy’s role is to notify you that authorization is required, transmit the prior authorization requirement information to your prescriber’s office, and, in some cases, facilitate electronic prior authorization requests through integrated systems that allow pharmacists to initiate the process and send the required forms directly to the prescriber.

Your role as the patient is to ensure that your prescriber’s office has received the prior authorization request and is actively working on it, and to follow up if the process stalls.

When your doctor’s office tells you to call the pharmacy, they may mean: go back to the pharmacy to get the specific authorization request form or reference number that the insurance company requires. When the pharmacy tells you to have your doctor call, they mean: the physician’s clinical documentation is what the insurance plan needs and the pharmacy cannot provide it.

The phone tag experience most patients describe is the result of a process that was designed by insurance companies with minimal regard for patient experience and that involves multiple parties who each hold one piece of a puzzle that nobody has assembled in advance.

The Step by Step Process for Getting Through Prior Authorization Faster

Step 1: Confirm the prior authorization requirement at the pharmacy. When your pharmacist tells you that prior authorization is required, ask them to tell you specifically: which insurance plan is requiring it, what the specific prior authorization code or requirement is, whether the pharmacy can electronically transmit the PA request to your prescriber’s office, and whether an emergency supply is available while the PA is processed.

Step 2: Contact your prescriber’s office immediately. Call the same day. Tell them specifically: the medication name and dose, the insurance plan name, and that the pharmacy has transmitted, or is transmitting, a prior authorization request. Ask them to confirm they have

Ask them to confirm they have received the request and to give you a specific timeframe for submission. Get the name of the person you spoke with and write it down.

Step 3: Ask your prescriber’s office for a peer to peer review if the PA is denied. If the insurance plan denies the prior authorization, your physician has the right to request a peer to peer review, a direct conversation between your prescribing physician and the insurance plan’s medical reviewer. Peer to peer reviews have a significantly higher approval rate than initial PA requests because they allow the prescribing physician to directly address the clinical rationale with a physician reviewer rather than submitting documentation into a form processing system.

Many physicians do not proactively offer peer to peer reviews because they are time consuming and add to an already full schedule. As the patient you can specifically request that your physician pursue a peer to peer review if the initial authorization is denied.

Step 4: Request an emergency or bridge supply from your pharmacist. For medications where interruption of therapy poses a genuine clinical risk, psychiatric medications, cardiovascular medications, seizure medications, and similar chronic condition drugs, ask your pharmacist whether an emergency supply can be dispensed while the authorization is pending. Many plans and state laws allow pharmacists to dispense a limited emergency supply, typically three to seven days, in situations where interruption of therapy would be harmful.

In Mississippi and most states pharmacists have authority to dispense emergency supplies of maintenance medications when there is a documented urgent need and the authorization process is actively in progress.

Step 5: Follow up every 48 hours until resolution. Prior authorization requests do not automatically escalate when they sit in a queue. Insurance plans have review timelines, typically 72 hours for standard requests and 24 hours for urgent requests under federal guidelines, but meeting those timelines requires that the submission was complete and received. Follow up with your prescriber’s office every 48 hours to confirm the submission is complete and the timeline is being met.

Step 6: Appeal a denial. If your prior authorization is denied, you have the right to appeal the decision. Your insurance plan is required to provide you with a written denial notice that includes the specific reason for denial and the instructions for filing an appeal.

Appeals are worth filing. Denial rates on initial PA requests are significant across the industry, but appeal approval rates are also meaningful, particularly when the prescribing physician provides additional clinical documentation or when the peer to peer review process has not yet been used.

The Prior Authorization Reform That Is Coming

Prior authorization has been the subject of significant federal legislative and regulatory attention in recent years.

The Centers for Medicare and Medicaid Services finalized rules in 2024 requiring certain health plans, including Medicare Advantage plans and Medicaid managed care plans, to implement electronic prior authorization, provide real time decisions for routine requests, reduce the timeframe for urgent PA decisions, and provide transparency in their PA requirements and approval rates.

These rules represent meaningful progress. They do not apply to all commercial insurance plans. The full implementation timeline extends through 2027 for some provisions.

Private insurer prior authorization reform has been slower and more varied by state. Mississippi has considered prior authorization reform legislation focused on reducing the burden on physicians and patients for common medications and conditions. The reform landscape continues to evolve.

What Your Pharmacist Can Do to Help

A pharmacist who is actively managing your care, rather than just processing your prescription transactions, can be a meaningful advocate in the prior authorization process.

At Fairview we can:

Identify that a PA is required before you leave the counter so you are not surprised days later when you call to check on your prescription.

Electronically transmit the PA request to your prescriber’s office through integrated systems that reduce the time between your pharmacy visit and your prescriber receiving the documentation needed.

Help you identify whether a formulary alternative exists that does not require prior authorization, and communicate that alternative to your prescriber as an option worth considering.

Dispense an emergency supply when clinically appropriate and legally permitted while the authorization process proceeds.

Contact your prescriber’s office directly when the PA process has stalled and patient harm from delay is a concern.

Help you understand the appeal process if your PA is denied, including what documentation is most likely to support a successful appeal.

None of these services require an appointment. They are part of what pharmacy practice is supposed to look like when the pharmacist is genuinely invested in the patient’s outcome rather than just the transaction.

The Honest Assessment of Prior Authorization

Prior authorization is a legitimate clinical tool that has been dramatically overextended into a cost containment mechanism that delays care, harms patients, and burdens physician practices with administrative work that has nothing to do with medicine.

The medications most commonly subject to prior authorization are not primarily high risk drugs requiring careful oversight. They are expensive drugs, brand name medications, specialty biologics, newer agents, where the insurance plan’s financial interest in reducing utilization has been dressed up in the language of clinical management.

This does not mean every prior authorization denial is wrong. Some are appropriate. Some PA requirements catch genuinely inappropriate prescribing. But the system as currently designed causes far more harm through delays and abandonments than it prevents through appropriate utilization management, and the evidence for this is documented in the medical literature, not just in patient frustration.

Understanding this context will not make your individual prior authorization experience less frustrating. But it will help you understand why persistent advocacy, following up, requesting peer to peer reviews, filing appeals, asking your pharmacist to help, is the correct response to a system that relies on patient passivity to achieve its cost containment goals.

This article is for general information only and is not a substitute for personalized medical advice. Before starting or changing any medication, including over the counter products and supplements, talk with your pharmacist or physician about your specific situation.