Last updated June 2026
Tina Aswani-Omprakash faces regular roadblocks accessing a drug she needs to treat her severe Crohn’s disease. Every six months her insurer requires her physician to complete a prior authorization review for a refill of a drug that helps control her medical condition.
“It is a nerve-wracking process each time,” said Aswani-Omprakash, of New York, N.Y.
That’s because nearly three years ago her insurer declined to cover the prescription. For almost a decade, Aswani-Omprakash had been taking a six-week dose of ustekinumab, rather than a standard eight-week course, because research showed this protocol may be more effective for patients with severe Crohn’s. But her insurer said it would only approve an eight-week cycle.
Aswani-Omprakash, 42, was terrified that if she had to scale back the dose, her symptoms, like debilitating fistulas in the genitals and rectum, would return. She had the option to pay out of pocket, but each dose costs about $26,000.
“It was really scary for me because before this drug I had tried many, many different drugs and none of them worked,” said Aswani-Omprakash, CEO of Illinois-based Strategic Alliance for Intercultural Advocacy in GI. “I had nearly two dozen surgeries. I could barely function. I lost about a decade of my life. When I finally started taking ustekinumab, it worked. I was finally able to go back to work, attend graduate school, and start a nonprofit.”
After both Aswani-Omprakash and her physician filed several appeals, the insurer eventually reversed course. But she and her doctor still must file a prior authorization request every six months.
“I just don’t know if I am going to be back where I was almost three years ago,” she said. “It’s very anxiety producing.”
Aswani-Omprakash is among many patients frustrated with the prior authorization policies of health insurance companies. Over a recent two-year period, about half of insured Americans said they were required to get approval before getting a medical service, treatment, or medication, and half of those patients said they had difficulty navigating the process, according to the Kaiser Family Foundation.
“Health insurance has become like the invisible hand in the doctor’s room that’s deciding what medicine and procedures you can have,” Aswani-Omprakash said.
What Is Prior Authorization?
Prior authorization was created by insurers, as early as the 1960s, as a check on high-cost, risky, and potentially unnecessary services, treatments, tests, and drugs. It requires a physician to demonstrate to an insurer that what they are prescribing for a patient meets medically necessary guidelines.
Services or procedures that often require prior authorization include most elective surgeries; high-cost and specialty drugs that require monitoring, such as biologics or cancer drugs; advanced imaging, such as MRI, CT, and PET scans; and use of medical equipment, like wheelchairs or hospital beds.
Sometimes prior authorization rules require a patient to try a different, less expensive drug (insurers call this “step therapy”), treatment, or test before the insurer will cover a pricier option recommended by a physician. And an insurer’s policies sometimes result in denying coverage for a physician’s recommended care if the health plan deems it experimental or lacking in evidence of efficacy.
Prior authorization rules are becoming more widespread. Beginning in 2026, traditional Medicare plans for the first time began requiring prior authorizations for more than a dozen procedures for beneficiaries living in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. Services subject to this new rule include certain knee surgeries, skin and tissue substitutes, and implementation of electrical nerve stimulators, according to CMS.gov.
Physicians and patient advocacy groups say the system—designed as a check on unnecessary patient care and fraud prevention—has gotten out of hand.
“Prior authorization is being applied to everything now, even generic drugs,” said Jack Resneck, M.D., chair of the University of California, San Francisco Department of Dermatology and former president of the American Medical Association (AMA).
The approval process means patients may have to wait days or weeks to learn whether their insurance will cover a treatment, drug, or diagnostic test. In 2024, the AMA surveyed 1,000 physicians and they reported that their practices spend 13 hours a week on average on prior authorization paperwork.
“It’s costing us time with patients, it’s hurting patient care, and it’s costing the health system even more,” Resneck said. “Patients are going to their pharmacies and can’t get their prescription filled. They don’t know what to do, and they get discouraged and give up. Then they show up in a doctor’s office a few months later with their disease worse and even more expensive to treat.”
AHIP, a trade association representing the U.S. healthcare insurance industry, says prior authorization is “an important patient safety check” and that most medical and drug claims are not subject to prior authorization. However, AHIP also acknowledges that insurers “recognize patients are often frustrated” by the process and announced that many of the insurance companies it represents pledged to make prior authorization faster and more transparent by January 1, 2026.
Many patients, however, are still likely to find the process complicated. Here are strategies for navigating prior authorization, according to a dozen healthcare experts and patient advocates.
1. Start Planning Before You See the Doctor
Insurance plans’ prior-authorization rules vary tremendously depending upon whether insurers are subject to federal regulations, like Medicare or Medicaid, are private plans offered by employers, or are offered in an Affordable Care Act (ACA) marketplace. Rules also vary from state to state.
Spend time understanding your insurance before heading to a doctor. Log on to your health insurance plan’s website to see if it lists the services and drugs that require prior authorization. Can’t find the rules? If you have employer-provided health insurance, ask a human resources manager or your company’s insurance agent for help. If you don’t have employer-sponsored coverage, call your insurer and ask which services require prior authorization.
“The most good you can do for yourself is to know your plan before you need it,” said Caitlin Donovan, senior director of the Patient Advocate Foundation, a nonprofit patient advocacy organization. “Because when you are dealing with an illness, it is exhausting, and the last thing you want to be doing is trying to figure out your health insurance, too.”
2. Urge Your Doctor to Help
Armed with what you learned, tell your physician you might need a prior authorization from your insurer if they prescribe a procedure, drug, or test, or advise you to follow a particular treatment plan. Ask the provider to help you fight any denial or delay. And ask if there is a backup plan if you can’t get authorization. For example: Could the physician provide you with free drug samples while you wait for the decision? “Make your doctor a partner with you in this prior authorization process,” Resneck said.
Appointments with doctors can be short, so if you didn’t have time to consult with the provider about your insurance, or if they didn’t know whether your insurance plan might deny any prescribed care, don’t leave the office until you’ve spoken with someone in the practice’s billing office. That person may know if you are likely to face a prior authorization challenge and what to do about it. Get the person’s contact information in case you need help later.
“Usually there is someone in the practice who handles prior authorization requests,” said Seth Glickman, M.D., a health services advisor and former health insurance executive. “Don’t leave until you find that person because they will know your insurance and what process you need to follow.”
Also, ask for a copy of your diagnosis and recommended treatment, including the insurance codes connected to them. You will need them if you have to appeal a prior authorization denial, Glickman said.
“Keep a paper trail with your medical records and test results,” said Julie Baak, practice manager at the Bridgeton, Mo.-based Arthritis Center. “Create a file or a journal where you can track all your communications with your doctor and the insurance company.”
3. Know Your Rights and Be a Squeaky Wheel
Find out if your insurer has a set time frame to make prior authorization determinations.
Beginning in 2026, insurers providing coverage under a Medicaid or Medicare Advantage plan are required to make decisions within 72 hours for urgent requests and within seven calendar days for nonurgent requests. If you have an ACA plan, insurers must decide on urgent requests within 72 hours and have 15 days to review nonurgent requests. But these deadlines don’t apply to prescription drugs; for those, you’ll need to check with your insurer.
Some states have stricter laws governing prior-authorization timelines for most types of health insurance plans.
In Illinois, insurers must respond to urgent requests within 48 hours and have five calendar days to review nonurgent requests. They have 15 business days to rule on appeals. And plans cannot retroactively deny coverage for routine services if the same care was previously authorized for an associated condition. To review requests, insurers must employ physicians in the same or similar medical specialties. When consumers change their health insurance coverage, the new companies must honor prior authorization determinations for 90 days.
For more details on your state’s prior authorization rules, click here for the National Association of Insurance Commissioners’ breakdown of state legislative action on prior authorization.
Note: Employers that “self-insure” aren’t governed by federal or state regulations on prior authorizations; you’ll have to ask your employer about any rules.
Stay engaged with your physician and healthcare plan. Call the insurer and point out any applicable rules. Call your doctor’s practice to make sure they have filed the proper paperwork in the time frame required by the insurer.
“Do the best you can to track how the request is moving through the system,” said Glickman, who faced a personal prior authorization odyssey for a diagnostic test in the summer of 2025. “Call the insurer’s customer service. Remind them you are a consumer. Sometimes that can help motivate them. Call your doctor and make sure they are on top of the process.”
4. Appeal a Prior Authorization Denial
Most patients don’t appeal. However, for those who do, around 80 percent get their insurer to fully or partially reverse its decision, according to the American Medical Association.
“My experience is that patients’ letters, in addition to the physician’s appeal, can make a difference,” said Baak, who files dozens of appeals on behalf of her clinic’s patients each week.
If your insurer denies a prior authorization request, start by asking your physician to appeal it. Insurers use a “peer-to-peer” process where a specialist familiar with your condition speaks with your physician to review the proposed treatment, test, or drug. As part of that conversation, your physician provides documentation and patient history to demonstrate the requested service follows evidence and established medical guidelines.
Health insurance plans have different timelines for when that peer-to-peer call must happen, so check with your insurer to find out when your doctor needs to begin the process and what medical records, and supportive medical research, is needed to back the treatment, service, or test.
You can also submit an appeal. The Patient Advocate Foundation has a helpful template; visit tinyurl.com/appeal-sample to make yours.
5. Enlist a Patient Advocate and Make Noise
If your doctor’s office won’t help, or if you aren’t comfortable making your own appeal, look for a nonprofit patient-advocacy organization that supports others with your condition. Many of them operate help lines with staff or volunteers who can assist you.
“You don’t have to figure this out by yourself,” said Brett McReynolds, policy advisor for Let My Doctors Decide, a nonprofit coalition of patient advocacy and provider groups working to reform the prior authorization process. “I suggest going to a nonprofit based on your unique situation. They can help.”
You can also hire a patient advocate. This will cost you from $90 to $200 an hour, but it may be worth the money if you have expensive care that an insurer won’t cover.
The Patient Advocate Foundation provides grants and employs about two dozen people who help patients navigate their insurance or other health-system-related issues for free.
Reach out to your member of Congress and let them know you aren’t getting the care you need. Many lawmakers dedicate staff to helping constituents with issues such as healthcare challenges. Reach out to your state regulators. Most states have consumer-assistance programs for people with health insurance problems. If you have employer-covered insurance, let your employer know you are having a problem.
You can also call federal regulators. The U.S. Department of Health and Human Services oversees Medicare, Medicare Advantage, and ACA plans, while the Department of Labor regulates employer-sponsored plans. Kaiser Family Foundation has a guide to understanding which group or agency regulates health insurance.
Finally, you can try shaming a health insurer by posting about your problem on social media.
“I’ve seen patients on X or Facebook just calling out their insurance company, saying ‘I cannot get the drug my doctor prescribed,’ and magically, sometimes the next day, it gets filled,” McReynolds said. “Shout from the rooftops that you’re not getting the care that you deserve.”