Prior authorization made clear:
Understanding how prior authorization works for prescription drugs
Prescription drugs play an important role in helping people stay healthy. They help treat illness and manage chronic conditions. These therapies also help prevent disease and improve the quality of life for millions of people.
At the same time, the number of new drugs available has grown rapidly in recent years. They have helped expand treatment options. But many new therapies are high cost for patients or require careful monitoring for safety. That’s why it’s so important to ensure they are used safely and appropriately.
Additionally, prescription drug costs continue to rise. The average annual cost of a brand‑name drug now approaches $13,000 — more than seven times higher than in 2006. Specialty drug costs have also increased significantly, exceeding $80,000 per patient annually in recent years, reflecting sustained growth over time.1, 2
These rising costs, combined with the growing number of available therapies, can make it harder for people to get the medications they need.
Prior authorization helps people access the right medications at the right time
Prior authorization for prescription drugs is a tool to help support safe, high-quality care and lower people’s out-of-pocket costs. It evaluates whether medications meet medical standards and are covered by a member’s benefit plan. For example, long-acting opioids may require prior authorization. This checks whether the medication is being used correctly.
Prior authorization may also help identify lower-cost alternatives for patients. These alternatives are clinically appropriate covered options for the same condition and typically help lower a member’s out-of-pocket costs — while maintaining effective treatment.
Why prior authorization matters
Prior authorization helps ensure certain medications are used safely and helps lower out-of-pocket costs for members. It may be needed because of a medication’s clinical complexity, potential safety risks, evidence-based uses and cost. Prior authorization helps make sure certain drugs support both good care and affordability. This process can help:
How prior authorization decisions are made
Prior authorization decisions are based on clinical evidence. All prior authorization requests that aren't automatically approved are reviewed and completed by qualified clinicians, including pharmacists and physicians. Decision times vary by plan type and request type, and the timeframes required by law. This includes Medicare Part D coverage determination and exception rules.
Clinical review criteria are developed using FDA-approved labeling, safety information, and medical and pharmacy research. They also use treatment guidelines and other widely accepted clinical resources.
Coverage criteria are reviewed and approved by the UnitedHealthcare Pharmacy & Therapeutics Committee. This committee includes external physicians and pharmacists.
By the numbers and what they mean
99%
of pharmacy claims do not need prior authorization7
Only a fraction of pharmacy claims require prior authorization
87.9%
of prior authorizations are approved8
Almost 9 out of every 10 prior authorizations submitted are approved
4 hrs
is the average decision time for prior authorization9
Nearly all decisions are made within 1 day
Making the prior authorization process easier for providers and patients
We’ve made sustained, meaningful investments to streamline and modernize prior authorization. These investments are making the process more automated, integrated and seamless. It’s largely invisible for providers and patients — while continuing to help ensure people get the medications they need.
Prior authorization isn’t always needed or can often be resolved quickly. Many commonly used medications, such as antibiotics and blood pressure, depression and cholesterol medications, typically don't require prior authorization.
When reviews are needed, UnitedHealthcare and Optum Rx have developed solutions that streamline and simplify the experience. These include automating reviews by using available data and integrating directly into the work providers already do. This helps minimize manual steps across the process.
A simpler process for providers and patients
Most pharmacy claims are processed in real time without prior authorization review. This allows immediate checks of eligibility, formulary or prescription drug list (PDL) status and other clinical requirements.
In fact, 99% of claims process without prior authorization.10 Common examples include medications to treat high cholesterol, high blood pressure, asthma, depression, substance use disorders, diabetes and many others.
For medications that need prior authorization, about half of prior authorizations for UnitedHealthcare are quickly confirmed. This often happens in real time, without needing to be submitted for a review.11 This is made possible by our data-driven programs that verify coverage for applicable plans.
- Matching diagnoses to medications – looks at existing medical and pharmacy claims at the time a prescription is processed. It checks whether the member already has an existing diagnosis on file and meets the clinical criteria. For example, some medications for type 2 diabetes can be approved immediately if the necessary diagnosis is already documented.
- Real-time pharmacy check – reviews prescription requests instantly using prior authorization history, therapy progression and member data. For example, with select women's health drugs to treat endometriosis, we evaluate internal information such as a diagnosis and the use of appropriate first-line therapies to bypass the prior authorization review and process.
- Ongoing treatment approvals – helps ensure members can continue taking medications they’ve already been approved for. If a medication used for a long-term condition — such as an autoimmune disease — was approved before, coverage can continue into the next year or after the approval period ends, as long as the plan rules and medical requirements are still met.
- Medication history checks – reviews past prescription claims at the time a new claim is made. It can confirm earlier approvals or show that required first-line treatments were already tried. This often allows medications — especially for chronic conditions — to be approved quickly without needing additional review.
Together, these seamless, automated approaches to decision making get rid of unnecessary steps and help people access the right medications quickly.
Faster, more automated decisions when prior authorization is needed
When prior authorization is required, existing clinical and claims information help support faster review. Requests may be approved without contacting the prescriber again. This can take out an extra step, saving time.
A solution includes:
- Alternative prior authorization approvals – supports coverage of a clinically appropriate medication when the originally prescribed drug does not meet criteria and is allowed by the benefit, while preserving applicable member rights. For example, when a drug has a step therapy requirement.
This tool reduces administrative work and decision time, helping patients get access to the right medications sooner.
Better support at the point of prescribing
Some prescribers and pharmacists have access to real-time information when making treatment decisions. This can help avoid delays before they happen.
- Real-time coverage and cost view – during the patient visit, when a medication is being prescribed, this tool shows whether it’s covered, what it may cost and if there are lower-cost alternatives available.
- Coordinated cancer treatment review – brings together the medical and pharmacy requirements for cancer treatment into one process. It allows a full treatment plan — including both oral and infused oncology medications — to be reviewed and approved at the same time.
Providing this information upfront helps make it more likely prescriptions are covered the first time.
Supporting access — even when a request changes
A prior authorization decision isn't always the end of the process. Patients often receive safer and more cost-effective treatments as an alternative. When a medication isn't approved as submitted, the next step is often one of these options:
- A covered alternative medication with the same treatment effects – for example, if an anti-inflammatory drug used to treat rheumatoid arthritis or psoriatic arthritis isn’t approved due to a patient not having tried its covered biosimilar. Instead, we provide an authorization for the preferred biosimilar if use of the medication meets clinical criteria.
- Additional clinical information is requested to support the review – for example, why the requested drug is medically necessary or why formulary/PDL alternatives aren't appropriate. Also, evidence that the drug is more effective for the patient, safer given patient-specific factors and required due to disease severity or progression. Measurable data supporting need, as appropriate, such as lab results (e.g., cholesterol), imaging findings, clinical scores (e.g., pain scales) and vital signs or functional assessments may also be needed.
- An adjustment that aligns with the member’s benefit plan – for example, for drugs with multiple strengths, we’d require use of 1 higher strength tablet instead of 2 lower strength tablets, which could double the cost for the member.
These steps result in members getting a therapy that meets medical guidelines for their care needs. It may also be more affordable for patients.
Continuously reducing prior authorization requirements
We are continually evaluating where prior authorization is no longer needed. When clinical evidence supports it, we’re removing requirements. Since 2022, UnitedHealthcare has removed prior authorization requirements completely or avoided initial and reauthorizations for approximately 25% of medications subject to review across commercial plans.12 Most recently, the prior authorization requirement was removed for a self-injectable drug to treat high cholesterol.
We regularly review each medication that needs prior authorization. This helps us decide if requirements can be removed or simplified. We base our decisions on clinical evidence and safety, how the medication is used and evolving standards of care.
Frequently asked questions
There are important differences between how pharmacy and medical prior authorization work. For prescription drugs, a claim is usually submitted first at the pharmacy counter or other point of sale. The system reviews it in real time. It checks for things like eligibility, formulary or PDL status, quantity limits for patient safety and prior authorization requirements. If prior authorization is needed, that process begins at that point, including evaluating internal data, which may allow the prescription to automatically process. If further review is required, the pharmacy, prescriber, member or representative may take next steps. These may include submitting a prior authorization or coverage determination request. For medical care, prior authorization often happens before a service is provided.
Pharmacy and medical prior authorization measure different parts of the care experience. In pharmacy, attempted claim volume can include duplicate fill attempts and both specialty and non-specialty drugs. Also, not every pharmacy claim under review needs a full prior authorization. Some requests can be approved automatically based on information already in the system.
Several things can affect the outcome, like the member’s coverage and the clinical details of the prescription. Common factors include:
- If the drug is covered on the member’s formulary or PDL
- Whether step therapy applies
- If the prescription is for a generic or brand medication
- Quantity limits or refill timing rules
- Whether enough clinical information has been provided to support coverage
A first decision is not always the end of the process. The prescriber may need to send more information for the request. Or, the member may be able to receive a different covered medication. They may get a lower-cost option or a change in supply or dosage that fits the benefit plan. If a request is not approved, there is also an appeals process. These steps help providers and members move forward with covered options that are aligned with the patient’s care plan. They may also help lower out-of-pocket costs.
All prior authorization requests that are not automatically approved are completed by qualified clinicians, including pharmacists and physicians. Decisions are based on clinical criteria and evidence. This includes FDA information, peer-reviewed literature and treatment guidelines. Decisions are made within the timeframes required by law. Timeframes vary by plan type, request type and applicable law, including Medicare Part D coverage determination rules.