You have an appointment with your doctor. They examine you, determine the right treatment, and write a prescription for the medication you need. You head to the pharmacy — and then you are told that your insurance company has to approve the medication before they will cover it. That process is called prior authorization, and for patients on specialty medications, it is one of the most common — and most frustrating — barriers to getting treatment on time.
This article explains what prior authorization is, why it exists, how the process works, and what happens when it is denied. Most importantly, it explains how QuickRx Specialty Pharmacy handles prior authorization on your behalf so you can focus on your health instead of your paperwork.
What Is Prior Authorization?
Prior authorization (PA) — also called preauthorization, prior approval, or precertification — is a requirement from an insurance company that your prescribing physician obtain approval before your insurance will agree to cover a specific medication or treatment.
According to the American Medical Association (AMA), prior authorization was originally introduced for brand-new, high-cost medications and has expanded significantly over the years — to the point where the majority of prescriptions written by many physicians now require some form of prior authorization. The AMA has reported that 96% of oncologists surveyed said their patients’ treatment had been delayed due to prior authorization requirements.
The intent, according to research published in PMC / NIH, is to ensure that a prescribed drug is medically necessary, clinically appropriate, and aligned with evidence-based guidelines before the insurer agrees to pay for it.
Why Do Specialty Medications Often Require Prior Authorization?
Specialty medications — those used to treat conditions like cancer, multiple sclerosis, rheumatoid arthritis, rare diseases, and other complex diagnoses — are among the most likely to require prior authorization. This is because they are typically:
- High in cost (often thousands of dollars per month)
- Brand-name with limited or no generic alternatives
- Used for complex conditions where alternative therapies may exist
- Subject to step therapy requirements, meaning insurers may require a patient to try a less expensive alternative first
Research published in PMC / NIH found that prior authorization was required for 47% to 71% of biologic medications for rheumatoid arthritis and asthma — and that it took between 6.7 and 21 days for insurance companies to process those requests. Every day spent waiting is a day a patient is not receiving their treatment.
How Does the Prior Authorization Process Work?
The prior authorization process typically follows these steps:
Step 1: The prescription is written
Your doctor prescribes the specialty medication. In many cases, neither the doctor nor the patient knows at this point whether the insurance plan requires prior authorization for that drug.
Step 2: The claim is rejected at the pharmacy
When the pharmacy runs your insurance, the claim is returned with a message that prior authorization is required. The pharmacy notifies the prescribing physician’s office.
Step 3: Clinical documentation is gathered
The prescriber’s office — or, in the case of a specialty pharmacy like QuickRx, our dedicated PA team — gathers the required clinical documentation. This typically includes your diagnosis codes, treatment history, lab results, and documentation of any other therapies that were tried first (if step therapy is required).
Step 4: The PA request is submitted to the insurer
The completed prior authorization form and supporting documentation are submitted to the insurance company. This can be done by phone, fax, or through an electronic platform. The insurer then reviews the request and determines whether to approve, request additional information, or deny.
Step 5: Decision and follow-up
Insurers are generally required to respond to standard PA requests within a defined timeframe — often 3 to 15 business days depending on state law and plan type. Urgent or expedited requests may be processed faster. If the PA is approved, the pharmacy can fill the prescription. If it is denied, the appeals process begins.
What Happens If Prior Authorization Is Denied?
A PA denial is not necessarily the end of the road. Patients and prescribers have the right to appeal, and many denials are overturned on appeal when additional clinical documentation is provided. According to research published in PubMed, pharmacy intervention in prior authorization management resulted in significantly shorter time to decision and higher approval rates compared to standard processes.
The appeals process typically includes:
- Internal appeal: A formal request for the insurer to reconsider its decision, typically including additional clinical evidence or supporting documentation from the prescriber
- Peer-to-peer review: Your prescriber speaks directly with the insurer’s medical director to discuss the clinical rationale for the medication
- External review: If internal appeals are unsuccessful, an independent third party reviews the case and issues a binding decision
Throughout this process, patients also have the right to request an expedited review if their condition is urgent — and insurers are typically required to respond within 24 to 72 hours for urgent cases.
What About Step Therapy (“Fail First”) Requirements?
Some insurance plans require step therapy — also known as “fail first” — before approving a specialty medication. This means the insurer requires the patient to try and fail on one or more less expensive alternative therapies before the requested medication will be covered.
Step therapy can be appropriate in some clinical situations, but it can also delay access to treatments that a physician has determined are right for a specific patient. When step therapy requirements conflict with a patient’s clinical needs, the prescriber can request a medical exception, which the PA team at QuickRx can help coordinate.
How QuickRx Handles Prior Authorization for You
At QuickRx Specialty Pharmacy, prior authorization management is a core part of what we do — not an afterthought. Our dedicated PA team works directly with prescribers to gather clinical documentation, submit requests, track status, and manage appeals so that you do not have to wait any longer than necessary for your medication.
We handle prior authorizations for specialty medications across all therapeutic categories, including oncology, multiple sclerosis, rheumatoid arthritis, rare diseases, movement disorders, and more. You can learn about our full range of prior authorization and specialty pharmacy services on our pharmacy services page.
If you have received a prior authorization denial, or if you are starting a new specialty medication and are not sure what your insurance requires, call our team at (917) 830-2525 — we are available 24/7. You can also reach us through our contact page.
Our patient navigator team — led by Julia Kravtsova, PharmD — will review your situation, contact your prescriber’s office, and begin the PA process as quickly as possible. In many cases we are able to have your medication shipped before the bureaucratic process is fully resolved, using bridge supply options when appropriate.
To learn more about how we help patients access and afford specialty medications, read our blog on how specialty pharmacies use technology to cut copay costs.
References
- What Doctors Wish Patients Knew About Prior Authorization. American Medical Association. 2023. ama-assn.org
- Benefits of Prior Authorizations. PMC / NIH. pmc.ncbi.nlm.nih.gov
- Prior Authorization and Utilization Management Concepts in Managed Care Pharmacy. PMC / NIH. pmc.ncbi.nlm.nih.gov
- The association between cost sharing, prior authorization, and specialty drug utilization. PMC / NIH. pmc.ncbi.nlm.nih.gov
- Examining the prior authorization process, patient outcomes, and the impact of a pharmacy intervention. PubMed. pubmed.ncbi.nlm.nih.gov
- Electronic Prior Authorization for Prescription Drugs. PMC / NIH. pmc.ncbi.nlm.nih.gov
Medically Reviewed by: Julia Kravtsova, PharmD — Head Patient Navigator, QuickRx Specialty Pharmacy
Written by: Paola Larrabure — Pharma Content Manager, QuickRx Specialty Pharmacy
Last Updated: April 2, 2026
Disclaimer: The information in this article is for general educational purposes only and does not constitute medical, legal, or financial advice. Prior authorization processes, timelines, and appeal rights vary by insurance plan, state law, and medication. Always consult your prescribing physician and a qualified specialty pharmacy team for guidance specific to your situation. QuickRx Specialty Pharmacy is a URAC- and ACHC-accredited specialty pharmacy licensed in all 50 states.
