The Prior Authorization Maze: Why Getting the Healthcare You Need Is Getting Harder
Jaclyn Mayo, a Massachusetts woman battling multiple sclerosis, found her path to improved mobility blocked not by her condition, but by her insurance company. After seven months of successful treatment with Zepbound, a medication that allowed her to walk with greater ease, her prescription was suddenly stalled due to an expired prior authorization. Mayo’s story, reported by KFF Health News on February 26, 2026, is increasingly common, highlighting a growing frustration for patients navigating the American healthcare system.
What is Prior Authorization and Why Does It Exist?
Prior authorization requires doctors to obtain approval from an insurance company before prescribing certain medications or procedures. Insurers say this process helps control costs and ensures patients receive evidence-based care. However, the process often creates significant delays and administrative burdens for both patients and physicians. The American Medical Association has criticized the current system as “opaque and overly complex,” leading to disruptions in care.
The Rising Cost of Red Tape: A Patient’s Perspective
Mayo’s experience underscores the challenges patients face. She was unaware her initial authorization had expired and faced weeks of uncertainty and worsening symptoms while waiting for re-approval. The lack of clear communication from her insurer compounded the problem. This isn’t an isolated incident; a recent KFF poll revealed that one in three insured adults considers prior authorizations a “major burden” to accessing healthcare.
Why Are Prior Authorizations Increasing?
The trend towards increased prior authorization requirements is linked to the rising cost of healthcare, particularly for newer and more expensive medications like GLP-1s. These drugs, while effective, are subject to greater scrutiny from insurance companies. Even low-cost generic drugs aren’t immune to the process, adding to the frustration.
Navigating the System: Practical Steps for Patients
While the system isn’t ideal, patients can take steps to minimize the impact of prior authorization requirements:
Grasp Your Renewal Dates
Contact your insurance company or pharmacy benefit manager to determine when your prior authorizations expire. Proactive tracking can prevent unexpected disruptions in treatment.
Don’t Delay Requests
Initiate the prior authorization process well before your current prescription runs out. Allow ample time for potential delays.
Expedited Reviews
If your health is at risk, ask your doctor to request an expedited review. Federal regulations now require quicker decisions for urgent requests, though this doesn’t yet apply to all medications.
Explore Alternatives
Discuss alternative treatment options with your doctor. Your insurance plan’s formulary may have different requirements for different medications.
Appeal Denials
Don’t hesitate to appeal a denial. Research suggests that approximately half of all appeals are successful. Provide detailed documentation to support your case, including evidence that other treatments have been ineffective.
New Federal Rules and Future Outlook
A federal rule that took effect on January 1, 2026, aims to streamline the prior authorization process for Medicare Advantage, Medicaid and Children’s Health Insurance Program plans, requiring quicker decisions on requests. However, the rule doesn’t currently cover medications, leaving a significant gap in patient protections. Experts like Miranda Yaver of the University of Pittsburgh suggest that systemic changes are needed to address the root causes of the problem, but political will remains a significant hurdle.
FAQ: Prior Authorization Explained
- What is a pharmacy benefit manager (PBM)? A third-party company that manages prescription drug benefits on behalf of health insurers.
- Can my doctor override a prior authorization denial? Not typically. The process usually requires an appeal to the insurance company or PBM.
- What if I need immediate access to medication? Ask your doctor about requesting an emergency supply while the prior authorization is pending.
- Where can I discover more information about prior authorization? KFF Health News (https://kffhealthnews.org/) and the American Medical Association (https://www.ama-assn.org/) offer valuable resources.
Did you know? You have the right to appeal a prior authorization denial. Don’t give up if your initial request is rejected.
Pro Tip: Keep a detailed record of all communication with your insurance company, pharmacy, and doctor regarding prior authorizations.
Share your own experiences with prior authorizations in the comments below. What challenges have you faced, and what solutions have you found?
