What Is Prior Authorization for a Prescription?
Prior authorization (often shortened to PA) means your insurance plan wants to review a prescription before it agrees to pay for it. It's common for brand-name drugs, higher-cost medications, drugs with cheaper alternatives, and medications with safety limits. Your prescriber's office usually submits the request, often electronically, with notes explaining why you need the medication.
A related request is a formulary exception: asking the plan to cover a drug that isn't on its list of covered drugs, or to charge a lower tier price. The process looks similar, but some plans use different deadlines, so the calculator asks which one you have.
How Long Does Prior Authorization Take? Federal Deadlines by Coverage
These are the latest decision times federal rules allow once the plan has everything it needs. Many requests are decided within a day, and many states require faster decisions for prescriptions.
| Coverage | Standard request | Expedited (urgent) | Appeal decision |
|---|---|---|---|
| Medicare Part D / Medicare Advantage drug plan | 72 hours | 24 hours | 7 days (72 hours expedited) |
| Medicaid | 24 hours | 24 hours | Managed care: 30 days (72 hours expedited) |
| Job-based (employer) plan | 15 days | 72 hours | 30 days (72 hours urgent) |
| Marketplace plan – prior authorization | 15 days | 72 hours | 30 days (72 hours urgent) |
| Marketplace plan – formulary exception | 72 hours | 24 hours | Independent review: 72 hours (24 expedited) |
Two details catch people out. First, the clock starts when the plan receives the request. For Medicare Part D exceptions it starts when the plan gets your prescriber's supporting statement, so a request missing paperwork hasn't really started. Second, employer and Marketplace plans may extend a standard request once, by up to 15 days, if they tell you why.
A 2024 federal rule (CMS-0057-F) set new 72-hour and 7-day prior authorization deadlines for many plans starting in 2026. It covers medical items and services, not prescription drugs, which already have the timelines above.
When Is a Request Expedited?
A request should be handled as expedited (urgent) when waiting the standard time could seriously jeopardize your life, your health or your ability to regain maximum function. In practice:
- Your prescriber asks for it, ideally stating why, on the request form or in the electronic submission.
- For Medicare Part D, if a prescriber says the standard timeline could seriously harm you, the plan must generally expedite it.
- You can ask too, but the plan decides unless a prescriber supports it.
Running out soon is a good reason to ask your prescriber whether the request qualifies.
Waiting and About to Run Out? What to Do
- Confirm the plan has the request. Call the number on your insurance card and ask for the date it was received and whether anything is missing.
- Ask about an expedited review through your prescriber.
- Ask your pharmacy about a short supply. Medicaid pharmacies can dispense at least a 72-hour emergency supply while a prior authorization is pending. Medicare Part D plans must offer a transition supply to new members and to members whose coverage of a drug changed.
- Compare the cash price for a few days' supply. Sometimes it's affordable as a bridge; use the copay savings calculator to compare.
- Ask your prescriber about an alternative the plan already covers, at least until a decision arrives.
Never stop a medication suddenly without talking to your prescriber. Some medications must be tapered.
If Your Prior Authorization Is Denied
A denial isn't the end. The notice must say why and how to appeal.
- Medicare Part D: ask for a redetermination within 65 days. If that's denied, an Independent Review Entity can reconsider it, then further levels follow.
- Medicaid managed care: file a plan appeal within 60 days, then you can request a state fair hearing.
- Employer and Marketplace plans: file an internal appeal within 180 days, then request an independent external review, generally within 4 months.
Strong appeals include a letter from your prescriber explaining medical necessity, what other drugs you've tried and why they didn't work, and relevant test results. The calculator shows the appeal deadlines once you know the decision date.
Prior Authorization and Your Refill Schedule
Prior authorizations are often approved for a set period, such as 6 or 12 months, and then must be renewed. Put the expiration date on your calendar and ask your prescriber to submit a renewal a few weeks early. If you track your medication in RefillDay, the pill refill date calculator shows exactly how many days you have left to plan around.