You have your prescription, but your treatment plan is paused. The prior authorization (PA) is a requirement from your insurance company that adds a bureaucratic barrier between you and your medication. Since a PA can take a few days or a few weeks, knowing how to check the status of medication before authorization is the best way to speed things up.
Don’t sit on the sidelines waiting for an automated update. Being proactive, tracking your PA’s progress, and understanding the system are essential steps to gaining control over your healthcare. This comprehensive guide provides you with the tools and support to navigate the process confidently.
Understanding Prior Authorization
Before you start tracking, it helps to know what you’re tracking. A prior authorization (PA) is a requirement put in place by your health plan, not your doctor, to determine if they will cover the cost of a specific medication or service.
What Prior Authorization Means in Prescription Coverage
A PA is essentially a pre-approval from your insurance company. When your doctor prescribes a specific drug, the PA process requires your healthcare professional to file formal paperwork with the payer proving that the drug is medically necessary and appropriate based on your diagnosis and medical history. Without this prior authorization, the insurer may refuse to pay, leaving you with the full, expensive, out-of-pocket price.
Why Health Plans Require Approval Before Certain Medications
The main goals of the PA are cost management and clinical safety. Insurance companies use PAs to:
- Manage Costs: Encourage the use of cheaper alternatives, like generics.
- Ensure Safety: Verify that high-risk drugs or those with potential for misuse are used correctly.
- Confirm Necessity: Ensure expensive, specialty medications are only prescribed when clinically justified.
Key Terms You Should Know: Formulary, Coverage, and Exceptions
- Formulary: The official list of covered medications for your health plan. Drugs not on this list (non-formulary) almost always require a PA (exception).
- Coverage: Refers to the extent to which your plan will pay for a drug. Even if a drug is on the formulary, coverage might be restricted.
- Exception: A formal request (often the PA) asking the plan to cover a drug they usually don’t.
Why Some Medications Require Prior Authorization
Certain types of medications are almost always subject to PA because they pose a financial or clinical risk to the payer.
Cost Management and Clinical Safety Reasons
The most common trigger for a PA is the cost. If your drug is expensive, the insurer wants a review. Additionally, drugs that require special dosing or have a potential for adverse health effects are flagged for clinical safety review.
Brand vs. Generic Drug Authorization Requirements
If a generic equivalent is available, and your doctor prescribes the brand-name drug, a PA is typically required. The doctor must provide detailed documentation showing that you either failed on the generic (known as step therapy) or that the generic caused an unacceptable side effect.
Specialty Drugs and High-Cost Treatments
Specialty medications (often injectable, infused, or used for complex diseases) are the top triggers for PAs. These treatments can cost thousands of dollars per month, necessitating a stringent review of medical necessity.
How the Prior Authorization Process Works
The PA process follows a defined path involving three teams: your doctor’s office, the pharmacy, and the insurance company.
Step 1 — Your Doctor Prescribes a Medication
Your healthcare professional decides which medication is best. If they suspect a PA is needed, they may start gathering the necessary clinical documentation immediately.
Step 2 — The Pharmacy or Provider Requests Authorization
When the prescription is sent, the pharmacy or the doctor’s office sends an initial inquiry to the insurer. If the insurer confirms the PA is required, the provider’s team will then file the detailed request form, including diagnostic codes and your history.
Anecdote: I once worked with a team whose new software install failed, leading to a system exception error that corrupted their registration data. For three days, they couldn’t submit electronic prior authorizations and had to switch to fax, a much slower method. This highlights how a single technical problem in a doctor’s office can delay your PA without you knowing.
Step 3 — The Insurance Company Reviews the Request
The insurer’s clinical teams review the submitted file. They check if the drug meets their internal coverage criteria and if the documentation supports the need for that specific medication. They may reach out to your doctor’s office with a question or ask for more documentation.
Step 4 — Approval or Denial Decision is Issued
The insurance company makes its final decision and sends a notice back to the provider and the pharmacy.
Average Review Time for Medication Requests
For standard requests with all paperwork completed correctly, the average review time is typically 1 to 3 business days. For complex specialty drugs or if there is missing documentation, it can easily extend to 5 to 7 days, or even several weeks if an appeal is necessary.
How to Track the Status of Your Authorization
This is the most critical part of the process. You need to treat the PA like a package delivery and check its status at every point. See the detailed section below on exactly how to check the status of medication prior aurithorization.
Checking Your Authorization Status
To find the current status of your PA, you need to contact the source—your insurance company.
How to Check Status with Blue Cross Blue Shield
Call the main customer support number on your insurance card. Ask for the Prior Authorization Department or the Pharmacy Benefits Team. Be sure to have your member ID, medication name, and prescribing doctor’s office information ready. Many Blue Cross Blue Shield plans also offer an online authorization portal where you can enter the PA reference number (obtained from your doctor) to track progress.
How to Track Prior Authorization with UnitedHealthcare
UnitedHealthcare and its affiliated plans often provide dedicated online tools or mobile apps for members. Log in to your account on the UnitedHealthcare website and look for a section labeled ‘Coverage’ or ‘Prior Authorizations’. You can search by drug or by a specific PA number provided by your provider.
Steps to Verify Status for Cigna or Aetna Members
Similar to other insurers, Cigna and Aetna members should first check the online dashboard. They often use third-party software interfaces (like CoverMyMeds, mentioned later). If the online tracking fails, call the number on the back of your card and ask for a status update on your prior authorization request, referencing the submission date.
How Pharmacies Update You on Status Changes
Your pharmacist is often the first to see the final approval or denial message. If a PA is required, the pharmacy’s system will show a temporary rejection code. When the status changes to ‘Approved’, the pharmacy will receive a new claim submission message and should notify you immediately. If you visit the pharmacy, they can manually check the live status in their system.
What to Do If Prior Authorization is Denied
A denial is not necessarily the final word. It just means the insurer said “no” to the initial request—but you have the right to appeal.
Understanding the Denial Reason in Your Notice
When your PA is denied, the insurance company is legally required to send a denial notice explaining the exact reason. Common reasons include: Failure of step therapy, lack of medical documentation, or the drug not being on the formulary. Understanding the reason is the first step toward a successful appeal.
Steps to File an Appeal Through Your Health Plan
- Internal Appeal: The first step is typically a formal appeal submitted by your doctor’s office to the insurance plan. This is usually done by providing new clinical notes to directly address the denial reason.
- External Review: If the internal appeal is also denied, you can request an external review, where an independent third-party doctor reviews your file.
How Your Doctor Can Help with a Resubmission
Your doctor is your best support. They can quickly draft the clinical documentation needed for a resubmission or appeal. Crucially, they can also request a peer-to-peer review—a direct phone call between your prescribing doctor and the insurance company’s medical reviewer to argue the medical necessity of your medication.
When to Request an Urgent or Expedited Review
If waiting for the standard timeframe could seriously jeopardize your life or health, your doctor can request an urgent or expedited review. This forces the insurer to provide a decision, often within 24 to 72 hours. Do not hesitate to ask your doctor’s office to file an urgent request if time is critical.
How Long Does Prior Authorization Take?
The duration of the PA process is highly variable, but understanding the typical review timelines helps you set expectations.
Typical Review Timelines by Insurance Type
- Standard Commercial Plans: 1 to 5 business days.
- Medicare Part D/Medicare Advantage: Often legally required to provide a standard decision within 7 days of receiving the request (or 72 hours for an expedited review).
- Medicaid: Varies widely by state, but generally follows similar expedited rules for critical medications.
Why Some Requests Take Longer Than Others
The single largest reason for delays is back-and-forth communication. If the insurance company sends a question to the doctor’s office that is not answered promptly, the clock stops ticking until the documentation is provided. Complex specialty drugs also require more scrutiny, adding time.
How to Avoid Delays in the Approval Process
Proactive patient management is key. Call your doctor’s office the day after the request is submitted to ensure they have the PA reference number and are ready to respond to any further inquiries.
Common Reasons for Delays and How to Fix Them
| Reason for Delay | Solution |
| Incomplete documentation (e.g., missing diagnosis codes) | Ask your doctor’s office to double-check the form before the initial submission. |
| The doctor’s office is slow to respond to an insurer’s question | Call the PA specialist at the office directly and ask if the insurer has sent any new questions they need to answer. |
| Old submission method (fax) | Ask your provider if they use an electronic authorization system (like CoverMyMeds) to ensure the fastest submission method. |
Common Medications That Require Prior Authorization
Specialty Medications and Biologics
These expensive drugs for conditions like rheumatoid arthritis or multiple sclerosis are almost always subject to PA.
Mental Health and ADHD Prescriptions
Certain high-dose or unique ADHD prescriptions and newer mental health medications can require PA due to the potential for misuse or high cost.
Weight Management and Hormonal Treatments
Weight management medications are often restricted by PAs because many plans view the treatment as cosmetic or non-essential unless a patient meets strict clinical criteria.
Injectable and Infusion Drugs
Because they involve high costs and often require professional administration, nearly all injectable and infusion drugs require PA.
Can You Speed Up a Prior Authorization?
While you can’t bypass the PA, you can use tools and methods to expedite the process.
How Doctors Can Use Digital Submissions to Save Time
The fastest way to send a PA is digitally. Electronic authorization systems allow doctors’ offices to complete the forms and send the file instantly to the insurer, cutting out the time lost waiting for faxes or mail.
Electronic Authorization Systems in Modern Healthcare
These systems (like CoverMyMeds or Surescripts) are designed to check PA requirements instantly and provide the correct forms. They are crucial software tools for reducing administrative burden.
Tips to Get Faster Responses from Insurance Providers
- Ask for the PA Reference Number: Always get the unique PA reference number from your doctor’s office. This speeds up all future follow-up calls with the insurer’s teams.
- Request an Expedited Review: Use the urgent request option when medically necessary.
The Role of Real-Time Data Exchange and Automated Forms
Modern healthcare systems are moving toward real-time data exchange, where the PA requirement is checked immediately at the point of prescribing, saving time and preventing rejections later at the pharmacy.
Medicare and Prior Authorization
Prior authorization rules vary depending on your specific Medicare plan type.
How Medicare Part D Handles Prescription Requests
Medicare Part D prescription drug plans often use PAs for specific medications on their formulary. They have clear, federally mandated timelines for review (7 days for standard, 72 hours for expedited).
What to Expect for Medicare Advantage Plans
Medicare Advantage (Part C) Plans often bundle medical and drug coverage, and they frequently require PAs for both medications and services (e.g., durable medical equipment or certain procedures). The rules are generally stricter than Original Medicare.
Differences Between Commercial and Federal Plan Rules
Federal plan rules (for Medicare) provide stronger patient protections regarding timeframes for decisions and appeal rights compared to many commercial plans.
Role of Patient Advocates and Support Services
If you feel overwhelmed by the complexity, professional support is available.
How Patient Advocates Can Help with Appeals
Patient advocates specialize in navigating the system. They work directly with your doctor’s office and the insurance company teams to gather all necessary documentation, file appeals, and persistently monitor the status and progress.
Support Groups for High-Cost Medication Approvals
Many non-profit organizations and pharmaceutical companies offer programs and support groups that can help you with financial assistance and PA navigation.
How to Find a Licensed Advocate Near You
Organizations like the National Association of Insurance Commissioners (NAIC) or state health departments can often point you toward licensed, independent patient advocates or support services in your area.
Tools and Resources to Simplify the Process
Online Authorization Portals
These third-party platforms facilitate instant electronic submission and are the backbone of modern electronic prior authorization (ePA). You can often create a free account to check if your request is being handled through their system.
Pharmacy and EHR Integration for Faster Processing
Modern Electronic Health Record (EHR) systems are now integrating directly with pharmacy systems to exchange real-time data, checking PA requirements the moment the doctor clicks prescribe, eliminating the error and delay caused by faxing.
Mobile Apps to Track Approval Status
Many large insurers and third-party support services offer mobile apps that provide real-time updates and notifications on your PA status, saving you repeated calls to the office or the insurer.
Patient Help Desks and Hotline Numbers
Use the dedicated Prior Authorization or Pharmacy Help Desk hotline numbers provided by your insurer—avoid the general customer service line for the fastest results.
Expert Tips for a Smoother Authorization Experience
Keep All Documents and Reference Numbers Handy
Every time you call your insurer, you will need the PA reference number and the date of submission. Keep a dedicated file or note on your phone with this essential tracking information.
Maintain Communication Between Doctor and Insurer
Act as the bootstrapper—the person who starts the action. If you haven’t heard anything in three days, call your doctor’s office to check for pending questions, then call the insurer to confirm the office has not missed an important message.
Use Online Dashboards to Track Real-Time Updates
Utilize online portals from UnitedHealthcare, Cigna, or Blue Cross Blue Shield for the best status visibility.
Request Written Confirmation After Each Decision
Whether approved or denied, request a written confirmation of the status and the expiration date of the prior authorization for your records.
Final Thoguts:
Mastering how to check the status of medication prior authorization is about converting passive waiting into proactive management. By knowing which teams to contact, which tools to use, and how to use the appeal system, you ensure the shortest possible timeframe from prescription to pharmacy. Don’t let a clerical error or a slow fax line delay your treatment. Take control of the process today.
Frequently Asked Questions:
How do I know if a prior authorization is approved?
Your pharmacy is usually the first to know because the system allows the claim to be processed. Your doctor’s office and the insurance company will also notify you by mail or electronic message.
How long does it take for a request to go through?
Standard requests generally take 1 to 5 business days. Complex cases can take longer, but urgent requests must be processed within 72 hours.
What if my prior authorization is denied?
You have the right to appeal. Work immediately with your doctor’s office to file an internal appeal, often requiring new documentation or a peer-to-peer review.
Can I switch medications instead of waiting?
Yes. If your doctor agrees, switching to an alternative medication that does not require a PA or is already on your formulary can be the fastest way to start treatment.
Why is my prior authorization taking so long?
The most common reasons are incomplete documentation from the doctor’s office or a delay in responding to a follow-up question from the insurer. File an urgent request if time is of the essence.
How can I follow up if I haven’t received a response?
Call the PA Department of your insurance company using the PA reference number and ask for the current status and the specific expected timeframe for the decision.
What are common reasons for delay or rejection?
Delay: Slow response from the provider to an insurer’s question. Rejection: Failure to prove medical necessity or failure to follow step therapy rules.
