How to get a medication pre-authorization approved

You leave your psychiatrist's appointment with a new prescription. Two days later you go to the pharmacy and the pharmacist says, "Your insurance needs prior authorization for this." A few more days pass, then a denial letter arrives in the portal. Now you have a medication you can't fill, an appointment that won't happen for another month, and rising worry. This is one of the most common pain points in modern psychiatric care — and it can be navigated.

Why prior authorization exists

Insurers use PA to manage cost. They want documentation that the requested medication is medically necessary, that cheaper alternatives have been considered, and that any required steps have been tried. PA is most common for:

• Newer brand-name antipsychotics (Vraylar, Caplyta, Rexulti, Cobenfy)
• Long-acting injectables
• Doses above standard ranges
• Medications outside formulary
• Combination prescriptions when monotherapy is the standard

Step 1: Confirm what is being asked

Call the insurer (or check the portal) and find out:

• Whether the issue is prior authorization, step therapy, or quantity limit
• What specific clinical criteria they are looking for
• The deadline for submission
• Whether expedited review is available (usually yes for psychiatric medications)

Step 2: Get the prescriber to submit

Prior authorizations are submitted by the prescriber, not the patient. Make sure your prescriber's office knows it is needed. A few helpful things you can do:

• Call the office and confirm someone has the request
• Ask them to use the insurer's electronic PA portal (faster than fax)
• Provide them with a clear list of medications you have tried and stopped (and why)
• Provide hospital discharge summaries if relevant

Step 3: Make the clinical case strong

A successful PA request usually contains:

• Diagnosis with ICD-10 code (e.g., F20.9 for schizophrenia, unspecified)
• Specific symptoms being targeted
• List of previously tried medications, doses, durations, and reasons for discontinuation
• Documentation of failures or intolerances
• Justification of the requested medication's specific benefits
• Citation of relevant guidelines (APA Schizophrenia Practice Guideline)
• Consequences of not approving (relapse risk, hospitalisation history)

For example: "Patient has schizophrenia (F20.9) with three documented hospitalisations and failed trials of risperidone (intolerable EPS), olanzapine (15 kg weight gain), and aripiprazole (severe akathisia). Patient is now stable on Vraylar with no side effects after 6 weeks. Discontinuation would risk relapse and rehospitalisation."

Step 4: Use step therapy override if needed

"Step therapy" requires you to try cheaper drugs first before approving the requested one. You can request an override if:

• You have already tried and failed the required steps
• The required steps are contraindicated for you
• The required steps are expected to be ineffective based on the patient's history
• Switching from a stable medication would risk decompensation

Many states have step therapy override laws specifically for mental health. Cite them in the appeal.

Step 5: Push for expedited review

For psychiatric medications, especially when stopping or switching could destabilise the patient, you can request an expedited (urgent) review. Insurers must decide expedited PAs within 72 hours under federal rules. Use this when:

• You are running out of medication
• Stopping could trigger relapse
• You are post-hospital discharge with limited supply
• Switching could destabilise a stable patient

Step 6: If denied, appeal

Most denials can be successfully appealed. The path:

1. First-level internal appeal — often just resubmitting with stronger documentation
2. Second-level internal appeal — often involves a peer-to-peer call between your prescriber and the insurer's medical director (highly effective when scheduled)
3. External review by an Independent Review Organisation

See our guide to appealing insurance denials for the detailed appeal process.

The peer-to-peer call

This is often the most effective single step. Your prescriber requests a call with the insurer's medical reviewer (often a psychiatrist) to discuss the case directly. Approval rates after peer-to-peer calls are typically 60-80% in published surveys. If your prescriber's office doesn't routinely do them, ask if they will.

Bridge supplies and samples

While the PA is being processed, ask for:

• A 7-day or 14-day "starter pack" or sample from the prescriber
• A "bridge prescription" of an alternative medication to keep symptoms stable
• Manufacturer "starter" or "bridge" programs — many makers of newer antipsychotics offer free 30-day supplies during the PA process

Use copay cards and assistance

Even after PA approval, copays can still be high. See our patient assistance programs guide to lower out-of-pocket cost.

If you're on Medicare or Medicaid

• Medicare Part D: antipsychotics are a "protected class," meaning plans must cover essentially all of them. PA may still apply, but denials of antipsychotic coverage can usually be appealed successfully. CMS publishes appeal procedures.
• Medicaid: rules vary by state, but most state Medicaid programs cover all major antipsychotics with PA processes that can be appealed through state fair hearings.

Practical things you can do

• Always check your formulary before leaving the prescriber's office — ask the staff to look it up
• Know which medications on your insurer's formulary are "preferred" — they usually skip PA
• Keep a one-page personal medication history with you (drugs tried, doses, reasons stopped)
• Don't wait for the prescriber's office to call you — call them after 48 hours
• Document every call — date, name, reference number
• If a pharmacy says "denied," ask whether your prescriber's office has been notified

When the system fails — escalate

• State insurance commissioner
• State Medicaid ombudsman (if Medicaid)
• Medicare beneficiary helpline (1-800-MEDICARE)
• NAMI HelpLine
• Patient Advocate Foundation case management

This article is for educational purposes only and is not medical advice, legal advice, or financial advice. Rules and benefit amounts change; verify current details with the relevant agency or a qualified professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.