For Jaclyn Mayo, managing multiple sclerosis is a daily calculation of balance and stability. The autoimmune disease, which damages the nervous system, had begun to compromise her coordination, making simple tasks like climbing stairs feel precarious. To regain steadiness, her physician prescribed Zepbound, a GLP-1 medication originally approved for obesity that also helped suppress her appetite and alleviate neurological symptoms.
For seven months, the treatment worked. Mayo slept through the night. The numbness in her hands faded. But in August, her pharmacy refused to refill the prescription. There was no warning letter, no email notification. The advance approval from her insurance company had simply expired.
“Why do I necessitate a prior authorization for something that I am already prior authorized to take?” Mayo asked. “If my doctor says that they want me on a medication, why does my insurance have another say in that?”
Mayo’s experience highlights a growing friction point in the American health care system: prior authorization. While insurers argue these protocols ensure safety and control costs, patients and providers increasingly view them as opaque barriers to necessary care. For those with chronic conditions, a lapse in coverage can mean a rapid return of debilitating symptoms.
The Administrative Burden on Patients and Providers
Prior authorization requires physicians to justify specific treatments to insurance companies before they are approved. While intended to verify medical necessity, the process often lacks transparency. Mayo discovered her approval had lapsed only after her prescription was rejected. When her doctor submitted the necessary paperwork, the fresh approval took seven to 10 business days.
During that waiting period, Mayo was off her medication for two weeks. Her sleep deteriorated, and the tingling numbness in her hands returned. She requested an expedited review, only to learn that the insurance company required her doctor, not her, to make the urgent request.
“That red tape was completely avoidable,” Mayo said. “And all that they needed to do was communicate clearly to me. And then I could have continued my medication without delays. But they didn’t.”
Mayo is not alone. A recent poll found that 1 in 3 insured adults call prior authorizations a “major burden” to accessing health care. The American Medical Association has described the process as “opaque and overly complex,” citing delays in care and significant administrative strain on medical practices.
Insurers maintain that these safeguards are necessary. AHIP, the insurer trade group, stated in an emailed communication that prior authorizations help ensure patients receive safe, evidence-based care and keep coverage affordable. However, experts note that scrutiny often intensifies with costly treatments, such as the GLP-1 class of medications Mayo relies on.
Understanding Federal Protections and Timelines
Patients navigating these hurdles should be aware of existing federal regulations designed to prevent indefinite delays. For employer-based plans, federal rules require that urgent requests be decided within 72 hours. A federal rule that took effect on Jan. 1 creates similar requirements for Medicare Advantage, Medicaid, and Children’s Health Insurance Program plans.
However, gaps remain. The current rule does not universally apply to all medications, leaving commercial insurance plans with varying policies. Kaye Pestaina, director of the Program on Patient and Consumer Protections at KFF, noted that the definition of “urgent” is often left to interpretation.
“No one knows the specifics of what urgent means,” Pestaina said.
Miranda Yaver, a professor at the University of Pittsburgh who studies health politics and administrative burdens, suggests that standardizing how insurance companies evaluate requests could prevent medical disruptions. While policymakers have the tools to solve the problem, political conditions often stall reform.
“It’s a solvable problem, if we have the will and the political conditions are ripe,” Yaver said. “I don’t reckon that they are at this particular moment.”
Strategies to Navigate Coverage Hurdles
Until policy changes take hold, patients must advocate for themselves within the existing system. Based on expert guidance and patient experiences, there are several steps individuals can take to minimize disruptions in their care.
Verify Expiration Dates Early
Individual insurance companies and specific plans often have different policies regarding how long a prior authorization lasts. Some may expire after six months, others after a year. Patients should contact customer service at their insurance company or pharmacy benefit manager to confirm the expiration date of their current approval.
“As you can imagine, that becomes an absolute nightmare,” said Dr. David Aizuss, chair of the AMA’s board of trustees. He noted that while expensive treatments are targeted, even low-cost generic drugs can trigger review.
Initiate Renewals Before Supplies Run Low
Administrative processes are rarely quick. Mayo made her initial refill request about a week before her medication was set to run out, resulting in a two-week gap in treatment. Patients are advised to build in time for potential errors or delays by contacting their provider well before their supply is depleted.
Request Expedited Reviews
If a delay threatens your health, request your doctor to request an expedited review. Insurance companies may not volunteer this option, but federal regulations often mandate faster decisions for urgent cases. Ensure your provider knows your medication supply status so they can justify the urgency to the insurer.
Explore Formulary Alternatives
Health plans maintain formularies, or lists of routinely approved medicines. Sometimes, switching to a different brand within the same drug class can bypass lengthy approval processes. Mayo’s doctor initially requested a different GLP-1, but when that faced delays, they switched the request to Zepbound, which was approved. However, patients should be aware that formularies can change, potentially triggering new authorization requirements.
File an Appeal if Denied
Submitting an appeal is critical even if success seems unlikely. Research indicates that people who appeal a prior authorization or claims denial win about half the time. When appealing, include detailed records. If seeking approval for a specific medication, provide documentation showing that other treatments were tried and failed.
“I actually just went through a prior authorization for my migraine drug,” Yaver said. “It actually went through remarkably quickly.”
The Path Forward for Health Coverage
As health care costs rise, the tension between cost containment and patient access is likely to intensify. New federal interoperability rules aim to make the prior authorization process more digital and transparent, but full implementation will take time. Patients should stay informed about their specific plan’s policies and maintain open lines of communication with their providers.
For now, the burden of navigation falls largely on the insured. By understanding expiration timelines, utilizing expedited review options, and persisting through appeals, patients can better protect their access to necessary treatments.
Disclaimer: This article is for informational purposes only and does not constitute medical or legal advice. Insurance policies vary widely. Consult your health care provider and insurance plan documents for guidance specific to your situation.
We invite our readers to share their experiences with health insurance hurdles in the comments below. Your stories help us identify systemic issues and advocate for clearer pathways to care.
