Prior authorization and appeals for prescriptions in the U.S.

Updated 2026-10-07 · Reviewed for accuracy by the EKO Labs team. Educational only; not medical advice.

Many U.S. health plans pay for certain prescription medicines only after they approve them first. This is called prior authorization (also "pre-authorization" or "PA"). It is common for newer or more expensive medicines, including many GLP-1GLP-1 (glucagon-like peptide-1) a hormone the gut releases after eating. It helps release insulin, slows stomach emptying and signals fullness. medicines. This guide explains how it works and what you can do if the plan says no. It is general information, not legal or medical advice; your plan documents set the exact rules.

What prior authorization means

Prior authorization is a check by your health plan before it agrees to cover a medicine. The plan compares your prescription with its coverage criteria, such as the diagnosis, lab results or medicines you have already tried. Approval means the plan agrees to pay under your benefits; you may still owe a copay. A denial does not mean your doctor cannot prescribe the medicine, only that the plan will not pay for it as requested.

Related plan rules

• Step therapy: the plan asks you to try a preferred medicine first and covers the other one only if the first did not work or was not appropriate for you.
• Quantity limits: the plan covers only a certain amount per fill or per month.
• Formulary: the plan's list of covered drugs. A medicine that is not on the list may need an exception request.

Who sends the request

Usually your prescriber's office sends the request to the plan, often electronically, with notes from your chart. The pharmacy may tell you a prescription "needs PA" when it tries to bill the plan. You can help by calling the number on your insurance card to ask what the plan needs, and by making sure your doctor knows which medicines you tried before and has your recent test results.

How long a decision can take

Deadlines depend on the type of plan:

• Employer group health plans (ERISA): for a non-urgent request made before you receive care, the plan generally must decide within 15 days; for an urgent request, within 72 hours.
• Medicare Part D drug plans: a coverage decision must be made within 72 hours, or within 24 hours when a fast (expedited) decision applies. For exception requests, the clock starts when the plan receives your prescriber's supporting statement.
• A 2024 CMS rule sets decision times of 72 hours (urgent) and 7 calendar days (standard) from 2026 for Medicare Advantage, Medicaid, CHIP and federal Marketplace plans, but it does not cover prior authorization for drugs.

Some states set their own deadlines for plans they regulate. Ask your plan which rules apply to you.

If the plan denies the request

The plan must send you a written notice that explains the reason and how to appeal. Read it carefully: it often says exactly which information was missing. Common next steps:

1. Talk with your prescriber. The office may be able to send missing records or ask for a "peer-to-peer" conversation with the plan's reviewer.
2. File an internal appeal. Under federal rules, most private plans must let you appeal, and employer plans must give you at least 180 days after the denial notice to do it. For an appeal about care you have not received yet, a group plan generally must decide within 30 days; urgent appeals must be decided within 72 hours.
3. Ask for an external review. If the plan keeps the denial, you can usually ask an independent review organization to look at it. Under the federal process you have four months after the final denial notice to ask, and an expedited external review must be decided within 72 hours.

Medicare Part D appeals

If a Part D plan denies a drug, you or your prescriber can ask the plan for a redetermination (the first level of appeal) within 65 days from the date of the coverage determination notice. The plan must decide within 7 days, or within 72 hours if the appeal is expedited. If it still says no, there are further levels, starting with an independent review entity. You or your prescriber can also ask for an exception, for example to cover a drug that is not on the plan's list, with a supporting statement from the prescriber.

Tips that help

• Keep copies of every letter, and write down the date, the name of the person and the reference number of every phone call.
• Ask the plan for its coverage criteria (clinical policy) for the medicine.
• Include a letter from your prescriber and relevant records, such as medicines you already tried and why they were stopped.
• Check the deadline on the denial notice and send your appeal early.
• If waiting could seriously harm your health, ask for an urgent (expedited) review.

Questions to ask your plan

• Does this medicine need prior authorization, step therapy or a quantity limit?
• What information do you need from my doctor?
• When will you decide, and how will you tell me?
• How do I appeal, and what is the deadline?
• Can I ask for an expedited review?

At EKO Labs, our team can answer your questions in Portuguese or English by phone.

Sources: 29 CFR 2560.503-1 (ERISA claims procedure); 45 CFR 147.136 (internal claims and appeals and external review processes); 42 CFR 423.568, 423.572 and 423.578 (Medicare Part D coverage determinations and exceptions); CMS, Redetermination by the Part D plan sponsor; CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) fact sheet. This guide is general information, not legal or medical advice.