Prior Authorization

Prior authorization requires a plan’s approval before it covers certain drugs, tests, or procedures. It is used to manage cost and appropriateness, and a denial can be appealed.

What is prior authorization, and how is it changing?

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Prior authorization is when your plan must approve a service or drug before it will pay. It’s used to control cost and confirm medical necessity, but it can delay care. In 2025 to 2026 the rules are tightening: CMS added Medicare Advantage guardrails, about 60 insurers pledged to cut it, and Texas limits AI-only denials and “gold cards” reliable providers out of it.