A woman with multiple sclerosis wanted to be able to walk up the stairs at home without losing her balance. Her doctor prescribed medicine that helped, but then approval from her insurance plan for the drug expired.

Medical Disruption from Expired Prior Authorization

Jaclyn Mayo, who has multiple sclerosis, said she was devastated when her weight loss medication, Zepbound, was abruptly cut off in August. The drug, a GLP-1 receptor agonist, had been helping her manage her symptoms and improve her mobility for seven months.

“Why do I need a prior authorization for something that I am already prior-authorized to take? If my doctor says that they want me on a medication, why does my insurance have another say in that?” Mayo asked. The situation left her without the medication for two weeks, causing her sleep and balance to worsen.

Mayo had been on Zepbound for less than a year when her pharmacy refused to refill the prescription. After multiple calls to her pharmacist, doctor, and insurance company, she learned that the prior authorization had expired. She said she never received a notice about the expiration, despite keeping track of her medical paperwork as a chronic illness patient.

“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.”

Why Insurers Use Prior Authorizations

Insurers require prior authorizations for certain treatments or tests, especially costly ones. When they do, your doctor has to make the preauthorization request to your insurance company, explaining why you need the treatment. Next, the insurer decides if it agrees that the care is medically necessary and if it will pay for it.

According to Miranda Yaver, a researcher at the University of Pittsburgh, the more costly the treatment, the greater the scrutiny. GLP-1 medications, which can cost hundreds of dollars per month, are often subject to prior authorization.

“Issues with prior authorizations are common,” Yaver said. “Policymakers could standardize how insurance companies evaluate prior authorization requests to prevent more Americans from experiencing medical disruptions. But I don’t think that they are at this particular moment.”

A 2024 letter from the American Medical Association (AMA) criticized the process, calling it “opaque and overly complex,” creating delays in care and greater administrative burden. A recent poll found that 1 in 3 insured adults call prior authorizations a “major burden” to accessing health care.

What Patients Can Do to Avoid Delays

Mayo’s experience highlights the need for patients to be proactive about understanding their insurance policies. Individual insurance companies, and even the individual plans within those companies, often have different policies for prior authorizations.

“As you can imagine, that becomes an absolute nightmare,” said David Aizuss, chair of the AMA’s board of trustees. To figure out how long a prior authorization lasts, patients should reach out to customer service at their insurance company or pharmacy benefit manager.

Getting a prior authorization isn’t always quick, so patients should build in time for things to go wrong. Mayo made the initial refill request about a week before her medication was set to run out and ended up without the drug for over two weeks.

Patients can also ask their doctors to request an expedited review. However, insurance companies and pharmacy benefit managers (PBMs) may not always volunteer that option. Federal regulations require that urgent requests made by people with employer-based plans be decided within 72 hours. On Jan. 1, a federal rule took effect that creates a similar requirement for all Medicare Advantage, Medicaid, and Children’s Health Insurance Program plans. However, this rule doesn’t apply to medications.

Mayo’s doctor initially requested approval for a different brand of GLP-1, Zepbound, after the initial request was delayed. The new medication was approved, but the delay caused her health to decline.

“Ask your doctor about treatment alternatives,” said Kaye Pestaina, director of the Program on Patient and Consumer Protections at KFF. Health plans have different formularies — lists of medicines that are routinely approved. It might be easier to switch medications than to fight to get your health plan to approve a specific one.

Patients should also consider other treatment options and stay informed about their insurance policies to avoid similar disruptions. As the debate over prior authorizations continues, policymakers are under pressure to find ways to streamline the process without compromising patient care.