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Prior Authorization

What is Prior Authorization

Prior authorization is a process used by insurance companies or third-party payors before they agree to cover prescribed medications or medical procedures. Insurance providers require prior authorization for reasons such as:

  • Age
  • Medical necessity
  • Availability of a generic alternative
  • Checking for drug interactions

A failed authorization can result in a requested service being denied, or an insurance company requiring the patient to go additional steps. The process can require a patient to try medication or a service preferred by the insurance provider, typically considered either more cost effective or safer, before the insurance company will cover a different service.

AUA Advocacy Efforts

When it comes to prior authorization issues, we’re working to support physician practices. Our advocacy efforts focus on reducing the burden that prior authorization causes practices and patients. In 2015, the AUA published a special white paper to support appropriate use of the Beers Criteria and its goal to improve effectiveness and safety of prescription practices for geriatric patients.

In October 2015, the AUA Board of Directors adopted a policy that reinforces our position that the Beers Criteria should not supersede clinical judgment or an individual patient’s values and needs, and that the list should not be used as a basis for coverage denials or prior authorization requirements. In 2018, the AUA reaffirmed adoption of the American Medical Association's Prior Authorization and Utilization Management Reform Principles.

Navigating Payor Forms

The AUA has also developed a prior authorization checklist, as well as a short guide to help with Payor Forms.

Contact Us

If you have additional concerns or questions, please email AUA at paymentpolicy@AUAnet.org.

Comments & Letters

Final Coalition Prior Authorization-MA Patients Over Paperwork Letter [pdf]
April 3, 2018


Beers Criteria Links

AUA Policy Statement on the Beers Criteria

AUA White Paper on the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults


Resources

AMA Prior Authorization Toolkit