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Getting Prior Authorizations

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What is a Prior Authorization?
  • Some insurance companies require you to get their approval before you get medical care or prescription drugs.
  • This is called prior authorization, pre-authorization, prior approval or pre-certification.
  • If you do not get prior authorization, your health insurance company may not pay for your care.
What Types of Medical Care Require Prior Authorization?
  • Medical care that often requires prior authorization includes drugs, tests, and medical procedures.
  • Prior authorizations are often used when a test or treatment may be unsafe when combined with other medications, should only be used for specific health conditions, or has a lower-cost option available.
Who’s Responsible for Getting the Prior Authorization?
  • Sometimes, your health care provider will start and coordinate the prior authorization process for you.
  • However, you may be responsible for getting the prior authorization yourself.
    • In this case, it is important that you review your health plan documents or call your health insurance company directly to find out what products and services require prior authorization, and your health insurance company’s specific process for getting prior authorization.
What Can You Ask Your Healthcare Team?
QuestionsWhy it matters

Are there any prescription drugs or medical care I am getting that require prior authorization? I want to make sure my insurance plan will cover my care.

Why it matters

Starting this conversation early and letting your doctor know cost is a priority may help them to proactively start the process

Will you submit the Prior Authorization for me? Is there any part of the process I am expected to take care of?

Why it matters

Figuring out what the doctor will take the lead on, and what you’re responsible for, will establish clear expectations and next steps

Is there any information I can provide to help information with the prior authorization process?

Why it matters

You may have additional information about your medical
history that can be helpful in the prior authorization process?

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Disclaimer: The information on this site is intended for U.S. residents only and is provided purely for educational purposes. Health, legal, regulatory, insurance, or financial related-information provided here is not comprehensive and is not intended to provide individual guidance or replace discussions with a healthcare provider, attorney, or other experts. All decisions must be made with your advisers considering your unique situation. © Triage Cancer & Pfizer Inc. 2024 

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Copyright © 2024 Triage Cancer.
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