Prior authorization is preapproval for medical services or prescription drugs that health insurance plans often require before they’ll cover the cost.
Typically, a provider or supplier submits forms to a health insurance plan to verify the need for a specific drug, piece of equipment or service. Plans put these requirements in place to avoid paying for unnecessary services or expensive procedures and drugs when a lower-cost version that’s available could work just as well.
Prior authorization also lets patients know ahead of time if their plan will approve something that’s not always covered rather than having to appeal a denial after the fact.
But how often and under what circumstances prior authorization is required depends on the health plan. While Original Medicare has a few prior authorization requirements, private Medicare Advantage plans and Part D prescription drug plans use this procedure more often.
