What is Prior Authorization?

Prior Authorization (PA) is a requirement that your treatment provider obtains approval from your health insurance plan to prescribe a specific medication or service. PA’s are seen by the insurance company as a technique for minimizing costs, wherein benefits are only paid if the medical care has been pre-approved by the insurance company. Without a PA, insurance plans may not pay for the medication or service. Even then, the insurance company – not the treatment provider- has the final say in the matter. And they can turn the patient down.

Why does it Matter?

Treatment should be individualized to meet the patient’s needs, there is not a “one size fits all” when it comes to treatment. Overly cumbersome PA’s that can cause a delay in access to care, have to be renewed frequently, do not treat the patient as an individual, and are not universal between payers. PA’s not only impact patient care, but also discourage providers from wanting to treat individuals who have a substance use disorder. Arbitrary limits for length of treatment, types of medications used, and requiring fail-first on less expensive medications, do not reflect patient-centered and evidence-based treatment for substance use disorder. Patients with addictions are unlikely to wait the hours or days it takes health insurers to approve the medications or services they need. These types of limitations perpetuate stigma, can set someone up to fail, and can even lead to death because people can’t access appropriate care in a reasonable timeframe. There’s no question reform is needed. The prior authorization process must be streamlined so patient care is no longer compromised.

How Do We Talk to Our Legislators?

Ask for the Prior-Authorization to be lifted. Prior authorizations create significant barriers for the providers to deliver timely and life-saving care to clients in need of addiction treatment. Any delay equals an increased risk of death. There are some insurance providers on their own accord lifted prior authorizations and have demonstrated how the elimination can reduce administrative burdens on providers, decrease overall costs, and improve outcomes.

The Numbers Don’t Lie: Prior Authorizations Hurt Patients

• 80 percent of prior authorization requests are ultimately approved – an indication that the current system may only delay treatment.
• 90 percent of physicians agree that the PA process delays patient access to necessary care.
• The average physician spends nearly 20 hours per week on PA activities.
• PA requirements and other administrative burdens cost $82,975 per physician per year.

Addiction Policy Advocacy Council (APAC) believes this one policy move would not only provide life-saving care to those that need it most, but also allow treatment providers to deliver high quality care without the burden of red tape.