How to get prior authorization for medication

Prior authorization for medication, often called a PA for medication, is a health plan’s approval of a drug before it pays for it. The prescriber’s office submits the request, and the benefit that covers the drug decides who reviews it. A drug the patient fills at a pharmacy usually goes to the plan’s pharmacy benefit manager. A drug your practice gives in the office, such as an infusion or an injection, usually goes to the health plan under the medical benefit.

The route matters because denials are common. 32% of physicians say their prior authorization requests are often or always denied, according to the AMA’s May 2026 survey of 1,000 physicians. A medication request sent to the wrong reviewer, or sent without the treatment history the plan’s policy asks for, comes back before anyone weighs the clinical case.

At a glance

• The pharmacy card names the pharmacy benefit manager, and the medical card names the health plan.
• Under Medicare, drugs a provider gives usually fall under Part B, and pharmacy drugs under Part D.
• Medicare drug plans must decide standard requests in 72 hours and expedited ones in 24 hours.
• The CMS decision deadlines for medical prior authorization from January 2026 exclude drugs.
• Silna handles authorizations under medical and behavioral health benefits.

Which benefit covers the drug

Every medication request starts by finding the benefit that pays for the drug, because the benefit decides who reviews the request and which rules it is judged against. A prescription prior authorization for a drug filled at a pharmacy is judged against the plan’s formulary. A drug your practice gives is judged against the health plan’s medical drug policy.

Medicare draws the line by where the drug is given. Part B usually covers drugs a patient would not give themselves, such as those given in a doctor’s office or a hospital outpatient setting, and Part D covers many drugs that Part B does not, according to Medicare’s guide to outpatient prescription drugs. Commercial and Medicaid plans also split drugs between a pharmacy and a medical benefit, and each plan’s policies say which drugs sit where.

The table compares the two routes.

Some payors review behavioral health benefits separately from medical benefits, sometimes through a separate company. When a patient’s plan works that way, confirm which reviewer handles the request before you submit it.

Coverage also changes over time. Many plans reset in January, and a patient’s benefits and authorization requirements can change with them. HealthPRO Heritage, a post-acute therapy provider, completed more than 10,000 benefit checks with Silna in under seven days in January 2026. The same work took nearly 60 days the year before.

How to get prior authorization for medication

The steps are the same for most plans. The reviewer and the channel are what change.

1. Confirm the benefit. Check which card covers the drug and who reviews it.
2. Check the criteria. Read the formulary or the medical drug policy for the drug.
3. Gather the documentation in the checklist below.
4. Submit through the right channel, before the drug is given when it is a medical-benefit drug.
5. Track the decision against the deadlines below, and log each reference number.
6. Act on a denial by resubmitting, requesting an exception or appealing.

Some health plans delegate review of medical-benefit drugs to companies such as eviCore and Carelon, covered in Silna’s guides to eviCore prior authorization and Carelon prior authorization. Pharmacy prior authorization requests go to the pharmacy benefit manager, and Silna’s guides to CVS Caremark prior authorization, OptumRx prior authorization, Express Scripts prior authorization and Prime Therapeutics prior authorization cover each manager’s process. A missing document is fixed by resubmitting, and a disputed clinical decision goes to an exception request or an appeal, as Silna’s guide to appealing a prior authorization denial explains.

Documentation checklist for a medication request

A complete request meets the plan’s criteria for the drug the first time it is reviewed. Before you submit, check that it includes:

• The member ID from the card for the right benefit, and the prescriber’s NPI
• The diagnosis and its ICD-10 code
• The drug, strength, dose, quantity and days’ supply
• The HCPCS code and site of care, for a medical-benefit drug
• Each drug already tried, with dates and why it stopped, when step therapy applies
• Chart notes and test results that meet the plan’s criteria
• The prescriber’s statement of the medical reason, for an exception request

How long a medication prior authorization takes

Medicare drug plans must decide a standard coverage determination no later than 72 hours after they get the request, and an expedited one no later than 24 hours, according to CMS’s August 2025 prescriber guide to Part D. A request qualifies as expedited when the standard timeframe could seriously jeopardize the patient’s life, health or ability to regain maximum function.

Medicare Advantage plans must meet the same limits for Part B drugs, the drugs covered under the medical benefit: 72 hours for a standard request and 24 hours for an expedited one, under federal regulations 42 CFR 422.568 and 42 CFR 422.572 as of October 2026.

Commercial plans follow state rules and their own policies. CMS’s newest limits, in effect since January 1, 2026, require Medicare Advantage, Medicaid and CHIP plans to decide prior authorizations within 72 hours for urgent requests and seven calendar days for standard ones. Those limits cover medical services and exclude drugs, according to the CMS fact sheet of January 17, 2024.

Physicians in the AMA’s May 2026 survey also linked prior authorization to harm to patients.

How Silna handles medication prior authorizations

Silna handles prior authorizations under medical and behavioral health benefits, including payors that review the two separately. It does not submit pharmacy-benefit requests to pharmacy benefit managers.

Silna tracks upcoming authorizations, sends weekly reminders, submits each request and follows up with the payor. A benefit check confirms the patient’s coverage and authorization requirements first, and Predictive Document Intelligence checks the request against the payor’s requirements before it is submitted.

ABS Kids, an ABA therapy provider, times each prior authorization from the moment a request comes in.

Silna has completed 8,927 prior authorizations for ABS Kids. Each one takes about an hour by hand, so Silna has saved ABS Kids’ staff about 8,900 hours.

Silna is the #1 rated prior authorization solution on G2, with a rating of 4.8 out of 5 across 66 verified reviews.

See how Silna handles medical-benefit prior authorizations

Key terms

Pharmacy benefit manager

The company that runs a plan’s pharmacy benefit, including its formulary, pharmacy network and drug prior authorizations.

Medical benefit

The part of a health plan that pays for care from providers, including drugs a practice gives and bills to the plan.

Formulary

A plan’s list of covered drugs, with the tier and any prior authorization, step therapy or quantity limit for each.

Step therapy

A plan rule that a patient try one or more other drugs before the plan covers the requested drug.

Exception request

A request that a plan cover a drug off its formulary, or waive a restriction such as step therapy, for a medical reason the prescriber states.

Frequently Asked Questions

Who submits a prior authorization for medication?

The prescriber’s office, usually staff working from the prescriber’s notes. When a claim is rejected for lack of prior authorization, pharmacy staff tell the office, but the clinical case comes from the prescriber.

How can a practice speed up prior authorization for medication?

Send a complete request electronically when the drug is prescribed, so the review starts before the patient’s fill or appointment. When waiting could seriously harm the patient’s health, ask for an expedited review, which a Medicare drug plan must decide within 24 hours.

Is there a prior authorization form for medication?

Each pharmacy benefit manager and health plan publishes its own forms, often one for each drug or drug class. Many accept the same information electronically from the EHR or a portal in place of a faxed form.

How long does a medication approval last?

Until the end date the plan sets, which is often tied to a course of treatment or the plan year. A patient who joins a new Medicare drug plan may get a one-time, 30-day transition fill of a drug they already take while the new plan’s prior authorization is requested, according to Medicare’s drug plan rules as of October 2026.

What happens if a medication prior authorization is denied?

The denial notice gives the reason, which decides the next step. A request sent under the wrong benefit is usually fixed by sending it to the right reviewer, without using an appeal.

Is drug prior authorization different from prior authorization for a procedure?

For pharmacy-benefit drugs, yes. The pharmacy benefit manager reviews them against the formulary, while procedures go to the health plan under its medical policy. A drug your practice gives usually follows the procedure route.

This article is general educational information and does not give medical or insurance advice. Coverage rules and clinical criteria vary by plan and state, so consult a licensed healthcare professional or your plan administrator about your specific situation.

About the author

Jeffrey Morelli

Jeffrey Morelli is the Co-Founder and CEO of Silna Health, the first Care Readiness Platform built to remove the administrative barriers that delay care. Silna automates benefit checks, eligibility, and prior authorizations across 1,000+ payors, and is backed by $27M from Accel and Bain Capital Ventures. Before Silna, Jeff spent a decade in San Francisco building and scaling products for highly regulated industries, including leading go-to-market at Truework (Series C, acquired by Checkr).

Last updated: October 13, 2026.