Understanding prior authorization
Prior authorization
Insurance approvals can feel confusing, especially when you’re focused on starting or continuing a treatment. Prior authorization is a common part of specialty care, and CVS Specialty® is here to guide you through the process.
What is prior authorization (PA)?
Prior authorization is when your insurance plan reviews certain medications, tests or treatments to determine coverage. This review helps confirm a medication is appropriate for your condition and medically necessary based on your plan’s guidelines.
What happens behind the scenes
When prior authorization is required:
- Your prescriber or CVS Specialty submits a PA request to your insurance plan and your prescriber sends any required documents
- Your insurance plan reviews the request to make sure the medication meets your plan’s coverage requirements
- When the review is complete, your insurance plan notifies you and your prescriber of their decision
- If a PA is approved, CVS Specialty will contact you to schedule medication delivery
- If a PA is denied, we’ll work closely with you and your prescriber to explore next steps, including alternative treatment options
Throughout this process, our CareTeam manages communication and keeps things moving forward.
How long do PAs take?
Most PAs take about a week, though timing can vary based on your insurance plan and the information required. You can track the status of your prescription within your CVS Specialty account.
Here’s a step‑by‑step walkthrough of a typical prior authorization process: CVS Specialty helps make sense of prior authorization
Reauthorization
Understanding reauthorization
After your insurance plan approves a specialty medication through its PA process, coverage usually lasts for a limited time. To continue treatment beyond that period, your plan may require reauthorization. This follow‑up review helps confirm the medication is still medically necessary and appropriate for ongoing use.
Initial approvals often last between one and six months depending on your insurance plan, the medication and clinical monitoring requirements.
The reauthorization process
When reauthorization is required:
- Your prescriber sends a reauthorization request before the current approval expires. This request should include updated clinical information to support continued medical necessity.
- Your insurance plan reviews the request and approves or denies continued coverage
- If approved, coverage continues for another set period
- If denied, your prescriber may appeal the decision or discuss alternative therapies with you
CVS Specialty works closely with your prescriber throughout this process to help avoid gaps in your treatment.
How long do reauthorizations take?
Reauthorizations generally take about one week, like initial prior authorizations. You can track the progress of your prescription status through your CVS Specialty account.
We are here to support you
If you have questions about prior authorization or reauthorization, our CareTeam is ready to help. After registering, you can chat with us online or call 1‑800‑237‑2767 (TTY: 711).
This information is not a substitute for medical advice or treatment. Talk to your doctor or health care provider about your medical condition and prior to starting any new treatment. CVS Specialty assumes no liability whatsoever for the information provided or for any diagnosis or treatment made as a result, nor is it responsible for the reliability of the content.
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