What to Know About Prior Authorizations for Medications

Takeaways

• Prior authorization is a rule requiring doctor approval before a health insurance plan pays for certain medications or services.
• Delays or denials can interrupt treatment for chronic conditions. Manage this by requesting refills early, appealing denials, and communicating with your doctor.

For many older adults, taking prescription medications is part of everyday life. Drugs for high blood pressure, diabetes, arthritis, heart disease, and other conditions help people stay healthy and independent. But sometimes patients discover that their prescription cannot be refilled, even when their doctor says they still need the medication. Often the culprit is something called prior authorization.

What Is Prior Authorization?

Prior authorization is a rule used by many health insurance companies. Before they will pay for certain medications or services, the insurer requires the doctor to explain why the drug or treatment is medically necessary for the patient. Only after the insurance company approves the prior authorization request will it cover the medication or service.

These requirements are most common for expensive medications, newer drugs, treatments that have cheaper alternatives, and drugs that insurers believe might be overused. If the authorization expires or the insurer changes its rules, patients may suddenly find that their prescription cannot be filled — even if they have taken the drug for years.

Why This Matters for Older Adults

Prior authorization delays can be more than an inconvenience. Many older adults depend on consistent medication to manage chronic illnesses.

When approvals are delayed, people may experience:

• Worsening symptoms
• Withdrawal effects from stopping a medication
• Increased risk of hospitalization
• Stress and confusion about what to do next

For people with chronic conditions, such as diabetes, heart disease, or autoimmune disorders, missing even a short period of treatment can cause significant health problems.

Why Prescriptions Get Delayed

Several things can trigger a prior authorization problem:

• The authorization expired. Some approvals only last a few months or a year. When they expire, a new request must be submitted.
• Insurance plans change. Insurance companies can update their list of covered medications (called a formulary) at any time.
• Paperwork problem. Missing documentation, incorrect codes, or delays between the doctor’s office and the insurer can slow the prior authorization process.
• Drug cost. More expensive medications tend to receive closer scrutiny from insurers.

How Prior Authorization Works in Medicare

Most older adults receive their health coverage through Medicare, but the experience with prior authorization can vary depending on the type of plan they have.

Traditional Medicare

Under traditional (Original) Medicare (Parts A and B), prior authorization is relatively limited. However, prescription drugs are usually covered through Medicare Part D, which is run by private insurance companies.

Part D plans often require prior authorization for certain medications, particularly high-cost drugs with less expensive alternatives.

Medicare Advantage

Many older adults are enrolled in Medicare Advantage plans, which are private insurance plans that replace Original Medicare coverage. These plans frequently use prior authorization not only for medications but also for medical services such as imaging tests, specialist visits, rehabilitation services, and certain medical procedures.

In recent years, federal regulators have introduced rules requiring Medicare Advantage plans to process many authorization requests faster and electronically. These changes are intended to reduce delays, but patients may still encounter challenges.

Ways Older Adults Can Cope With Prior Authorization Problems

Although the system can be frustrating, several strategies can help reduce delays.

• Request refills early. Don’t wait until you are almost out of medication. Since approvals can take days or even weeks, request refills well in advance.
• Track when authorizations expire. Ask your doctor or insurance company how long the authorization lasts and mark the expiration date on your calendar.
• Ask about expedited reviews. If going without medication could harm your health, your doctor can sometimes request an expedited review, which requires the insurer to make a faster decision.
• Consider alternative medications. Your doctor may be able to prescribe a similar drug that your insurance company covers more easily.
• Appeal a denial. If your insurer refuses to cover a medication, you have the right to appeal. Many appeals succeed, especially when your doctor explains why other treatments are not appropriate.
• Stay in contact with your doctor’s office. Most medical practices have staff members who specialize in insurance paperwork. Calling to check on the status of a request can sometimes help move things along.
• Keep records. Save letters from your insurer and keep a list of medications you have tried in the past. This information can be helpful if you need to file an appeal.

A New Wrinkle for 2026

Starting in 2026, a pilot program called WISeR (Wasteful and Inappropriate Service Reduction) will require Original Medicare participants to get prior authorization for certain services — but only in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.

This program is supposed to run through the end of 2031 and covers procedures that the government has flagged as potentially prone to overuse or fraud, including skin graft procedures, electrical nerve stimulators, and knee arthroscopy for knee osteoarthritis. If you live in one of the six participating states and have Original Medicare, talk to your doctor about whether this will affect any of your planned treatments.

The Bottom Line

Prior authorization is intended to control costs and ensure that treatments are medically appropriate. But for older adults who rely on prescription drugs to manage chronic conditions, the process can sometimes delay needed care.

Understanding how prior authorization works, especially within Medicare, and planning ahead can help reduce the chances that paperwork will interrupt your treatment. Staying organized, communicating with your doctor, and knowing about your right to appeal can make the process easier to navigate.

Additional Reading

For additional reading on topics related to health care for seniors, check out the following articles:

• Turning 65? What to Know About the 4 Parts of Medicare
• Entering and Leaving Medicare Advantage Plans
• Medicare Part D Plans 2025: Prescription Drug Coverage
• Does Medicare Cover Prescription Weight Loss Drugs?
• 2027 Will Bring Lower Prices for 15 Medicare Part D Drugs
• Is Purchasing Canadian Drugs Legal?