Prior authorization is defined as “approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan”.  It is also known as precertification, pre-authorization, prior approval, and predetermination. The premise of prior authorization is for insurance companies to determine if a prescribed product or service will be covered. The process is often bogged down with lengthy, intricate steps that often delay patient care. Several medical, hospital, and insurance associations in 2018 issued a consensus statement that clearly delineated the need for reforms to reduce prior authorization burdens and promote patient-centered care. Recently in response, some states have enacted or have considered enacting legislation to streamline or eliminate prior authorization in some cases.

First, in September 2021 Texas enacted a law that allows prescribers to earn a “gold card” exemption from prior authorization requirements based on their track record of previous prior authorization approvals from insurers including Medicaid managed care organizations and health maintenance organizations (HMOs). If a provider achieves a 90% approval rate on prior authorizations, then it earns a one “rolling approval” for ordering the same drug or test. Another key feature of the law is that physicians must have the opportunity to speak to a Texas licensed physician of same or similar specialty during the prior authorization process.

Another state, California, has passed a bill that prohibits health care insurers that already cover biomarker testing from requiring prior authorization for patients with advanced stage cancer. Eliminating this requirement means that deadly treatment delays due to prior authorization roadblocks are ended.

Legislation, however, is not the only avenue to removing or limiting the prior authorization process. States can remove prior authorization for medications in their Medicaid programs through informal regulatory actions, such as removing authorization requirements on the fee-for-service preferred drug list or by issuing guidance. Attorney generals across the US have urged insurers to remove prior authorization requirements for opioid use disorder medications. Roadblocks to timely care that lead to poor clinical outcomes should continue to fall by the wayside.

Learn More – Primary Resources

Prior Authorization – HealthCare.gov Glossary | HealthCare.gov

Consensus Statement on Improving the Prior Authorization Process

Bill Text – SB-535 Biomarker testing. (ca.gov)

Texas House Bill 3459

Prior Authorization: Overwhelming Burden and Critical Need for Reform

Influence of payer coverage and out-of-pocket costs on ordering of NGS panel tests for hereditary cancer in diverse settings

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