What is prior authorization?
Prior authorization — sometimes called “prior auth” or “PA” — is a requirement from your insurance company that your doctor get approval before prescribing certain medications. The insurance company reviews clinical documentation to decide whether they’ll cover the drug. Until that approval comes through, the pharmacy can’t dispense the medication and you can’t start treatment.
This applies most often to biologic medications (like adalimumab, etanercept, infliximab, and others), JAK inhibitors (like tofacitinib and upadacitinib), and some specialty drugs. These are often the most effective treatments in rheumatology — and also the most expensive, which is exactly why insurers want to review them first.
Why does this exist?
The honest answer: cost control. Insurance companies use prior authorization to manage spending on high-cost medications. They want to confirm that cheaper alternatives have been tried first, that the diagnosis is correct, and that the medication is being used for an approved indication.
Whether this process actually improves care or simply delays it is a matter of ongoing debate in medicine. What we can tell you is that we deal with it every day, we know how to navigate it, and we won’t let it stand between you and the treatment you need.
What our team does
You don’t need to submit the prior authorization yourself — that’s our job.
- We prepare and submit the request — this includes your diagnosis, relevant lab work, imaging, treatment history, and clinical documentation showing why this medication is appropriate for you
- We follow up — prior authorizations don’t always get reviewed on time, and we track every submission to make sure nothing falls through the cracks
- We respond to insurance questions — if the insurer asks for additional information, we provide it promptly
- We communicate with your specialty pharmacy — so that once approval is granted, your medication can be shipped or prepared without additional delays
How long does it take?
- Standard requests — typically 3 to 7 business days, though some insurers are faster and some are slower
- Urgent requests — if your condition requires rapid treatment, we can submit an expedited or “urgent” prior authorization, which most insurers must process within 24 to 72 hours
- Appeals — if the initial request is denied, the appeal process adds additional time — sometimes 2 to 4 weeks depending on the insurer and appeal type
We’ll keep you informed throughout the process. If there’s a delay, you’ll hear from us — you shouldn’t have to wonder what’s happening with your medication.
What you can do to help
While we handle the heavy lifting, there are a few things that keep the process moving smoothly.
- Answer calls from your insurance or specialty pharmacy — they may need to verify information, schedule delivery, or confirm your address
- Pick up or accept delivery of your medication promptly — some specialty medications are temperature-sensitive and can’t sit at a pharmacy indefinitely
- Let us know if your insurance changes — a new plan, new employer, or switch from commercial to Medicare can require a brand-new prior authorization
- Be patient, but speak up — if you haven’t heard anything after a week, call our office so we can check the status
What happens if you’re denied
Denials happen. They’re frustrating, but they’re not the end of the road.
- Peer-to-peer review — your doctor speaks directly with the insurance company’s medical reviewer to explain why this medication is necessary for you
- Letter of medical necessity — a detailed written appeal documenting your clinical history, failed treatments, and why the requested medication is the right choice
- External review — if internal appeals are exhausted, you or we can request an independent external review by a third party
Denials are common and are frequently overturned on appeal. A denial does not mean your doctor was wrong to prescribe the medication — it means the insurance company needs more convincing. We don’t give up easily.
Step therapy
Some insurers require step therapy — meaning they want you to try one or more cheaper medications before they’ll approve the one your doctor actually prescribed. For example, they might require you to try methotrexate before approving a biologic, even if there are clinical reasons to skip that step.
When step therapy is medically inappropriate — because you’ve already tried and failed the required drug, because you have a contraindication, or because your disease is severe enough to warrant going straight to the prescribed medication — we advocate for an exception. We submit the documentation, we make the phone calls, and we push back when the requirement doesn’t make sense for your care.
The bottom line
Prior authorization is an unavoidable part of modern rheumatology. We wish it weren’t, but it is. What we can promise is that our team treats it as a priority, not an afterthought. We’ll fight for your medication, keep you in the loop, and get you started on treatment as quickly as the system allows.
This handout is provided for educational purposes and does not replace individualized medical advice. Always follow the specific instructions given by your rheumatologist.